After Breast Conservation, 1 in 4 Women Have Repeat Surgery

Alexander M. Castellino, PhD

November 12, 2014

One in four women who undergo breast conservation surgery (BCS) for stage 0 to II breast cancer return for more surgery, according to an analysis published online November 12 in JAMA Surgery.

The incidence of second breast cancer surgeries has remained steady at approximately 25%, first author Lee G. Wilke, MD, of the University of Wisconsin School of Medicine and Public Health, Madison, told Medscape Medical News.

The study analyzed data from the National Cancer Data Base, which covers about 70% of cancer patients in the United States. However, the remaining 30% of cancer patients not captured in this database may have had other results, Dr Wilke noted.

This analysis was undertaken prior to new guidelines on margins in breast cancer surgery, which were published in January 2014, as reported by Medscape Medical News.

These new guidelines should reduce re-excision rates, commented Julie A. Margenthaler, MD, associate professor of surgery at the Washington University School of Medicine and the Siteman Cancer Center, who authored a related commentary.

The new guidelines, published as a consensus statement by the Society of Surgical Oncology in conjunction with the American Society of Radiation Oncology, encourage breast cancer surgeons to adopt "no tumor on the ink" as the standard definition of a negative margin for early-stage invasive breast cancer, regardless of personal biases.

Both Dr Wilke and Dr Margenthaler were of the opinion that re-excision rates following BCS should significantly decrease if the new guidelines are implemented.

The current study "will provide an excellent historical reference for future investigation of the success of this paradigm shift," Dr Margenthaler wrote in the invited commentary, which she coauthored with Aislinn Vaughan, MD, of the Sisters of St. Mary's Breast Care, St. Charles, Missouri.

Initial Lumpectomy, Additional Surgery

Dr Wilke and colleagues, including senior author Katherine Yao, MD, who is also from the University of Wisconsin School of Medicine and Public Health, Madison, analyzed data for January 1, 2004, through December 31, 2010. They found 314,114 women with stage 0 to II breast cancer who underwent an initial BCS for invasive breast cancer or ductal carcinoma in situ.

Of these patients, 76% underwent a single lumpectomy. However, 24% of women underwent at least one additional surgery. Of these, 62% had a complete lumpectomy, and 38%, a mastectomy.

Dr Wilke and colleagues examined patient demographic aspects, tumor characteristics, and facility characteristics to determine factors that contributed to repeat surgery.

Repeat surgery was seen at a higher frequency with larger tumors and in younger women, Dr Wilke told Medscape Medical News.

In women who had a tumor measuring 1.5 cm on initial surgery, 21% of patients had repeat surgery. For women whose tumor measured less than 5 cm, nearly half (48%) had a repeat surgery.

Additionally, the repeat surgery rate was 39% in women aged 18 to 29 years and 17% in women older than 80 years.

Repeat surgery rates also varied by region: 27% and 18% in the Eastern and Mountain regions, respectively. Facilities in the Mountain region were 36.0% less likely to perform repeat surgery (odds ratio, 0.64; 95% confidence interval, 0.61 - 0.68) compared with facilities in the Northeast.

Academic or research facilities had a significantly higher rate of repeat surgeries: 26% vs 22% for community facilities (P < .001).

Adopting "No Tumor on Ink" Recommendation

Repeat surgery following initial BCS is undertaken because a complete removal of breast cancer is regarded as the best way to reduce recurrence and improve survival.

The definition of what is considered a negative margin differs among surgeons, Dr Wilke told Medscape Medical News. This has been one factor that has led patients to undergo repeat surgeries, she added.

However, second surgery does not mean reduced survival. This study does not provide survival information and does not correlate second surgery with survival, Dr Wilkes told Medscape Medical News.

Dr Wilkes and colleagues hope that "these findings can be used by surgeons to better inform patients regarding repeat surgery rates and how patient or tumor characteristics influence these rates."

According to Dr Wilke, these data support the adoption of guidelines regarding re-excision after initial BCS.

Standard definitions of adequate margins, as set forth in the consensus guidelines and the indications for re-excision, will likely decrease the wide variation in repeat surgery rates and decrease costs and patient anxiety surrounding tumor-positive margins, Dr Wilke and colleagues conclude.

Dr Margenthaler again emphasized the need to adopt "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," Dr Margenthaler and Dr Vaughan write in their commentary.

As evidence, they indicated that although Dr Wilke and colleagues were unable to obtain exact pathologic margin width, more than 92% of the patients had negative margins. Nonetheless, a significant percentage of these patients underwent additional surgeries despite having margins that were "negative at ink."

"We should reduce the re-excision rates through examination of surgical performance and though the adoption of a standard definition of negative margins," Dr Wilke told Medscape Medical News. Surgical coaching will potentially improve these surgical outcomes, she added.

The authors and the invited commentators have reported no relevant financial relationships.

JAMA Surgery. Published online November 12, 2014.

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