What is an Adequate Margin for Breast-Conserving Surgery? Surgeon Attitudes and Correlates
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Re-excision is common in breast-conserving surgery (BCS), partly due to lack of consensus on margin definitions. A population-based surgeon sample was used to determine current attitudes toward margin width and identify characteristics associated with margin choice.
Breast cancer patients treated from 2005 to 2007 were identified from Los Angeles and Detroit Surveillance, Epidemiology, and End Results (SEER) registries. Pathology reports were used to identify their surgeons, who were surveyed (n = 418). Response rate was 74.6% (n = 312). Mean surgeon age was 51.9 years, 17.8% were female, and mean number of years in practice was 18.5.
Wide variation in margin selection was noted among surgeons, and did not differ for invasive cancer and ductal carcinoma in situ (DCIS). In a scenario of T1 invasive cancer, 11% of surgeons endorsed margins of tumor not touching ink (TNTI), 42% of 1–2 mm, 28% of ≥5 mm, and 19% >1 cm as precluding need for re-excision before radiotherapy. On multivariate analysis, having 50% or more of practice devoted to breast cancer independently predicted smaller margin choice (p = 0.03). For a patient with a 1.4-cm grade 2 estrogen receptor (ER)-positive DCIS without radiotherapy (RT) planned, 3% of surgeons chose TNTI, 12% 1–2 mm, 25% ≥5 mm, and 61% >1 cm as sufficient without re-excision. In the scenario of DCIS without RT, breast specialization independently predicted larger margin choice (p = 0.03). Gender and years in practice were not predictive of margin choice.
Wide variation in BCS margin definition exists. Variation is similar for invasive cancer and DCIS with RT, with more specialized surgeons choosing smaller margins. In DCIS without RT, more specialized surgeons favored larger margins. A standardized margin definition may significantly affect re-excision rates.
- Fisher B, Anderson S, Bryant J, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–41. CrossRef
- Poortmans PM, Collette L, Horiot JC, et al. Impact of the boost dose of 10 Gy versus 26 Gy in patients with early stage breast cancer after a microscopically incomplete lumpectomy: 10-year results of the randomised EORTC boost trial. Radiother Oncol. 2009;90(1):80–5. CrossRef
- Darvishian F, Hajdu SI, DeRisi DC. Significance of linear extent of breast carcinoma at surgical margin. Ann Surg Oncol. 2003;10(1):48–51. CrossRef
- Morrow M. Breast conservation and clear margins: invasive or in situ involvement. Breast. 2009;18(suppl 1):S12 abstract S28.
- Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg. 2002;184(5):383–93. CrossRef
- Dillon MF, Hill AD, Quinn CM, et al. A pathologic assesment of adequate margin status in breast-conserving therapy. Ann Surg Oncol. 2006;13(3):333–9. CrossRef
- Swanson GP, Rynearson K, Symmonds R. Significance of margins of excision on breast cancer recurrence. Am J Clin Oncol. 2002;25(5):438–41. CrossRef
- Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of re-excision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol. 2008;15(5):1297–303. CrossRef
- Morrow M, Jagsi R, Alderman A, et al. Surgeon recommendations and receipt of mastectomy for breast cancer. JAMA. 2009;302(14):1551–6.
- Greene FL, Page DL, Fleming ID. AJCC cancer staging manual, 6th ed. New York: Springer-Verlag; 2002.
- Janz NK, Mujahid MS, Hawley ST, et al. Racial/ethnic differences in adequacy of information and support for women with breast cancer. Cancer. 2008;113(5):1058–67. CrossRef
- Mujahid MS, Janz NK, Hawley ST, et al. The impact of sociodemographic, treatment, and work support on missed work after breast cancer diagnosis. Breast Cancer Res Treat. 2009; (Epub ahead of print). doi:10.1007/S10549-009-0389Y.
- Rockwood TH, Sangster RL, Dillman DA. The effect of response categories on questionnaire answers: context and mode effects. Sociol Methods Res. 1997;26(1):118–40. CrossRef
- Taghian A, Mohiuddin M, Jagsi R, et al. Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg. 2005;241(4):629–39. CrossRef
- Sarrazin D, Le MG, Arriagada R, et al. Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol. 1989;14(4):177–84. CrossRef
- Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227–32. CrossRef
- Wright MJ, Park J, Fey JV, et al. Perpendicular inked versus tangential shaved margins in breast-conserving surgery: does the method matter? J Am Coll Surg. 2007;204(4):541–9. CrossRef
- Wiley EL, Diaz LK, Badve S, Morrow M. Effect of time interval on residual disease in breast cancer. Am J Surg Pathol. 2003;27(2):194–8. CrossRef
- Wapnir I, Anderson SE, Mamounas E. Survival after IBTR in NSABP node negative protocols B-13, B-14, B-19, B-20 and B-23. J Clin Oncol. 2005;28(8 s):suppl; abstr 517.
- Nguyen PL, Taghian AG, Katz MS, et al. Breast cancer subtype approximated by estrogen receptor, progesterone receptor, and HER-2 is associated with local and distant recurrence after breast-conserving therapy. J Clin Oncol. 2008;26(14):2373–8. CrossRef
- Bijker N, Meijnen P, Peterse JL, et al. Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in situ: ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853—a study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol. 2006;24(21):3381–7. CrossRef
- Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol. 1998;16(2):441–52.
- Silverstein MJ, Lagios MD, Groshen S, et al. The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med. 1999;340(19):1455–61. CrossRef
- Hughes L, Wong M, Page D, et al. Local excision alone without irradiation for ductal carcinoma in situ of the breast. A trial of the Eastern Cooperative Oncology Group. J Clin Oncol. doi:10.1200/JCO.2009.21.8560.
- Wong JS, Kaelin CM, Troyan SL, et al. Prospective study of wide excision alone for ductal carcinoma in situ of the breast. J Clin Oncol. 2006;24(7):1031–6. CrossRef
- Kaufmann M, Morrow M, von Minckwitz G, Harris JR. Local–regional treatments of primary breast cancer. consensus recommendations from an international expert panel. Cancer. 2009;(Epub October 2009).
- What is an Adequate Margin for Breast-Conserving Surgery? Surgeon Attitudes and Correlates
Annals of Surgical Oncology
Volume 17, Issue 2 , pp 558-563
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- 1. Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
- 2. Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- 3. Department of Radiation Oncology, University of Michigan, Ann Arbor, MI, USA