Ten Ways to Cut Epidemic of Breast Cancer Reoperation

Nick Mulcahy

August 12, 2015

Breast cancer surgeons and care teams can do better in terms of their rate of reoperation after initial lumpectomy, according to a special panel of experts who have created a "toolbox" to reduce the problem of too many follow-up surgeries.

Reoperation rates vary widely among institutions and surgical practices in the United States, from less than 10% to more than 50%, the toolbox developers explain in their report, published online July 28 in the Journal of Surgical Oncology.

The rates are so high that they have been recently described as an "epidemic" by surgical oncologists, as reported by Medscape Medical News.

To address this ongoing problem, the American Society of Breast Surgeons (ASBS) convened a special multidisciplinary consensus conference in May, entitled the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER).

The new toolbox is the fruit of that conference, and seeks to reduce "the gap between actual and achievable care" in breast cancer surgery, write Jeffrey Landercasper, MD, from the Gundersen Health System in La Crosse, Wisconsin, and colleagues.

What should the national rate of lumpectomy reoperation be? The conference attendees, who included experts representing surgery, radiology, pathology, plastic surgery, radiation, and medical oncology, could not agree on that. In the United States, the average in four national databases currently ranges from 20% to 24%. Ten of the 15 conference attendees wanted to see the rate drop below 20%. But there was no emphasis on an actual number, Dr Landercasper said.

He explained why in an email to Medscape Medical News: "Many surgeons, some not present during the consensus conference, argue that setting a specific target goal, especially if it is very low, will have the unintended consequences of 'risk aversion' or increasing the mastectomy rate."

The following 10 reoperation-reducing "tools" — which are actually recommendations — can be "implemented into clinical practice quickly," but are not intended to represent a standard of care, which is a term that has legal implications, the team points out.

Compliance with the SSO-ASTRO margin guideline. The recent Society of Surgical Oncology (SSO)/American Society for Radiation Oncology (ASTRO) guidance — published in 2014, as reported by Medscape Medical News — indicates that surgeons should not routinely reoperate when there are "close" margins with "no tumor on ink" in patients with invasive breast cancer. Implementation of this tool could have "the most immediate impact," said Dr Landercasper, and could reduce reoperations by 40%. That number is based on his research, which demonstrated that 40% of re-excisions performed by ASBS-member surgeons before the margin guideline was issued were due to "ink negative close" margins.

Preoperative diagnostic imaging. Perform mammography, which is the standard, and use ultrasound selectively. Tomography and MRI are not fully recommended.

Minimally invasive breast biopsy. The approach means that preoperative treatment planning can include genetic risk assessment, medical oncology, and plastic surgery consultation and axillary evaluation.

Multidisciplinary discussions. Knowing, preoperatively, the number of lesions, geometry, distance to skin and chest wall, and possible extension toward the nipple could all facilitate negative margins.

Localization methods for nonpalpable breast lesions Radioactive seeds, intraoperative ultrasound, and wire localization to direct lesion excision are all recommended.

Oncoplastic techniques. These can reduce the need for reoperation in anatomically suitable patients, and have the potential to decrease positive margins at initial lumpectomy by allowing resection of a larger volume of tissue.

Specimen orientation of three or more margins. When the cancer is excised, markers or ink should be placed on the specimen for orientation to ensure that positive margin edge(s) guide focused re-excision of the correct tissue, if needed.

Specimen radiograph with surgeon intraoperative review. The primary reason is to show that the targeted lesion is removed. But it can also direct, in real-time review, any needed cavity shave.

Cavity shave margins. In patients with a tumor size of T2 or greater, or T1 with extensive intraductal carcinoma, consider this technique. A recent randomized controlled trial showed that cavity shave, compared with no shave, resulted in a significant decrease in the reoperation rate after lumpectomy, as reported by Medscape Medical News.

Intraoperative pathology assessment of lumpectomy margins. This can help decrease re-excision, when feasible, but is dependent on resources and expertise.

Improving the re-excision rate after initial lumpectomy, ultimately, is a group effort, and not just a surgeon's doing, Dr Landercasper explained.

"A surgeon's and an institution's re-excision rate is a composite measure of everyone's performance and the level of communication between them. A positive margin or a need for re-excision cannot easily be assigned or attributed to any single-care provider, specialty, or process of care or tool. In my opinion, it is all about the team," he said.

The CALLER conference was supported by the Gundersen Medical Foundation and Dune Medical Devices. The authors have disclosed no relevant financial relationships.

Ann Surg Oncol. Published online July 28, 2015. Abstract

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