Surgeon, Patient Factors Predict Breast-Conserving Surgery Reoperation

The likelihood of breast-conserving surgery reoperation is falling but remains significantly linked to surgeon experience and patient factors

medwireNews: A study of patients in New York State, USA, suggests that patients are becoming less likely to require reoperation after breast-conserving surgery (BCS) but that surgeon variability and patient demographical factors influence this outcome.

Almost a third (30.9%) of 87,499 patients who underwent BCS for primary breast cancer between 2003 and 2013 required reoperation because of a positive tumour margin, report Art Sedrakyan, from Weill Cornell Medical College in New York, and co-workers.

The rate fell significantly over the study period, from 39.5% of 16,805 patients in 2003–04 to 23.1% of 22,286 patients in 2011–13, they report in JAMA Surgery.

However, the 90-day rate of reoperation varied significantly between surgeons, from 0% to 100% of procedures, with 19.7% of the 2299 surgeons having a reoperation rate above 50%.

The majority (90.8%) of surgeons performed less than 14 BCS procedures per year and these had a reoperation rate of 35.2%; by comparison the reoperation rate was 27.5% for the 2.4% of surgeons who completed at least 34 BCS procedures per year.

“The extreme variability regarding reoperations among surgeons indicates a need for professional societies to provide guidelines and education to surgeons and trainees”, the authors say.

However, they caution against the use of reoperation rates as a qualitative metric to avoid unintended consequences such as excessively large excisions and poor cosmetic outcomes.

Instead, the team suggests that “[e]mphasis should remain on performing the correct operation for the correct indication because future guidance is developed using surgeon- and patient-reported outcomes data.”

In multivariate analysis, reoperation was significantly associated with a low annual case volume (odds ratio [OR]=1.49 versus high volume) and shorter duration of surgical career (OR=1.49 for 9–24 versus ≥32 years).

But reoperation was also significantly more likely in women aged 20–49 years and 50–64 years compared with older patients (OR=1.47 and 1.21, respectively), in Black or other race patients than in White patients (OR=1.07 and 1.13, respectively) and in women with carcinoma in situ than other tumour types (OR=1.57).

And reoperation was significantly less common in women with a low or medium comorbidity score than their high comorbidity score counterparts (OR=0.73 and 0.78, respectively) and in patients with non-commercial health insurance (OR=0.88 and 0.85 for Medicaid and Medicare versus commercially insured patients, respectively).

Discussing these variations in reoperation rates in an accompanying comment, Uttara Nag and E Shelley Hwang, from Duke University Medical Center in Durham, North Carolina, USA, write: “Sources of inconsistency may include surgeon training and volume, radiographic evaluation, and pathologic processing.

“In addition, subjective elements of surgeon bias may play a role because the authors’ multivariable analysis demonstrated that repeated excisions were significantly more likely in younger patients and those with fewer comorbidities.”

Acknowledging recent Society for Surgical Oncology–American Society for Radiation Oncology consensus guidelines recommending “no ink on tumour” as the standard of treatment for BCS, the commentators add: “As these guidelines for margin status are widely adopted, identification of persistent outliers to these guidelines and assessment of the effect of this practice change on surgical outcomes and value of care for early stage breast cancer should remain important goals.”

References

Isaacs AJ, Gemignani ML, Pusic A, et al. Association of breast conservation surgery for cancer with 90-day reoperation rates in New York State. JAMA Surg 2016; Advance online publication 17 February. doi:10.1001/jamasurg.2015.5535

Nag U, Hwang ES. Reoperation for margins after breast conservation surgery. What’s old is new again. JAMA Surg 2016; Advance online publication 17 February. doi:10.1001/jamasurg.2015.5555

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