Abstract
Background
Margin assessment is an essential component of breast conservation surgery (BCS). Re-excision of infiltrated margin(s) detected on paraffin section histology (PSH) needs reoperation, adding time, inconvenience and cost. Intra-operative assessment of margins using frozen section histology (IFSH) can potentially obviate need for re-operation, thus facilitating one-step oncologically complete BCS.
Methods
IFSH and PSH reports of consecutive patients undergoing BCS (2010–2020) were reviewed. Accuracy and cost-efficacy of IFSH were assessed, considering PSH as gold standard. Cost of achieving oncologically complete BCS in whole cohort with IFSH (Scenario-A) was calculated and compared using appropriate statistical tests, with hospital costs for the cohort in a hypothetical Scenario-B, where IFSH was presumed not to have been used and all patients with infiltrated margin(s) on PSH would have been re-operated.
Results
Of the 367 patients screened, 39 were excluded due to incomplete IFSH data. Of 328 patients analyzed, 59 (18%) had one or more margins were reported infiltrated on IFSH, managed by re-excision or mastectomy in the same sitting, thus avoiding a reoperation. Additional 8 (2.4%) had involved margins on PSH (False negative IFSH). Significantly higher number of reoperations (p < 0.001) would have been needed in scenario-B. Average cost of the first operation with use of IFSH was Indian Rupees (INR) 25791 which included INR660 as IFSH cost. The average cost of reoperation was INR23724 which could be avoided in 59 (18%) by use of IFSH. The average cost per patient to achieve oncologically complete surgery in scenario A utilizing IFSH was significantly lower (p = 0.001) by INR3101 (11.7%), c.w. that in scenario B. Significant cost-saving with IFSH was maintained in cost-efficacy analysis undertaken with various higher and lower costs assumptions.
Conclusions
Use of IFSH facilitates one-step oncologically complete BCS in majority of patients and results in considerable cost saving, resulting in avoidance of reoperations, besides preventing patient anxiety and delay in adjuvant treatment.
Trial Registration
Clinical Trials Registry—India (CTRI/2021/08/035896).
Similar content being viewed by others
Grant support
Nil
References
Osako T, Nishimura R, Nishiyama Y et al (2015) Efficacy of intraoperative entire-circumferential frozen section analysis of lumpectomy margins during breast-conserving surgery for breast cancer. Int J Clin Oncol 20:1093–1101
Osborn JB, Keeney GL, Jakub JW et al (2011) Cost-effectiveness analysis of routine frozen-section analysis of breast margins compared with reoperation for positive margins. Ann Surg Oncol 18:3204–3209
Jorns JM, Visscher D, Sabel M et al (2012) Intraoperative frozen section analysis of margins in breast conserving surgery significantly decreases reoperative rates: one year experience at an ambulatory surgical center NIH Public Access. Am J Clin Pathol 138:657–669
McCahill LE, Single RM, Aiello Bowles EJ et al (2012) Original contribution scan for author video interview variability in reexcision following breast conservation surgery. JAMA 307:467
Agarwal G, Ramya V, Mishra A, et al (2020): Oncoplastic breast conservation surgery for patients with large breast cancers undergoing primary or post-NACT breast conservation surgery is safe and effective. Cancer Res 80:P4-13-07.
Jorns JM, Daignault S, Sabel MS, Wu AJ (2014) Is intraoperative frozen section analysis of Reexcision specimens of value in preventing Reoperation in breast-conserving therapy? Am J Clin Pathol 142:601–608
Boughey JC, Hieken TJ, Jakub JW et al (2014) Impact of analysis of frozen-section margin on reoperation rates in women undergoing lumpectomy for breast cancer: evaluation of the National Surgical Quality Improvement Program data. Surgery (United States) 156:190–197
Morrow M, van Zee KJ, Solin LJ et al (2016) Society of surgical oncology-American society for radiation oncology-American society of clinical oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. J Clin Oncol 34:4040–4046
Buchholz TA, Somerfield MR, Griggs JJ et al (2014) Margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer: American society of clinical oncology endorsement of the society of surgical oncology/American society for radiation oncology consensus guideline. J Clin Oncol 32:1502–1506
Wang J, Deng JP, Sun JY, et al (2019) Noninferior outcome after breast-conserving treatment compared to mastectomy in breast cancer patients with four or more positive lymph nodes. Front Oncol 9
Moran MS, Schnitt SJ, Giuliano AE et al (2014) Society of surgical oncology-American society for radiation oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Int J Radiat Oncol Biol Phys 88:553–564
Wright MJ, Park J, Fey J et al (2007) Perpendicular inked versus tangential shaved margins in breast-conserving surgery: does the method matter? J Am Coll Surg 204:541–549
Agarwal G, Sonthineni C, Mayilvaganan S et al (2018) Surgical outcomes of primary versus post-neoadjuvant chemotherapy breast conservation surgery: a comparative study from a developing country. World J Surg 42:1364–1374
Jorns JM, Daignault S, Sabel MS et al (2017) Frozen sections in patients undergoing breast conserving surgery at a single ambulatory surgical center: 5 year experience. Eur J Surg Oncol 43:1273–1281
Dupont E, Tsangaris T, Garcia-Cantu C, et al (2021) Resection of cavity shave margins in stage 0-III breast cancer patients undergoing breast conserving surgery a prospective multicenter randomized controlled trial
Cartagena LC, McGuire K, Zot P et al (2021) Breast-conserving surgeries with and without cavity shave margins have different re-excision rates and associated overall cost: institutional and patient-driven decisions for its utilization. Clin Breast Cancer 21:e594–e601
Thill M, Baumann K, Barinoff J (2014) Intraoperative assessment of margins in breast conservative surgery—still in use? J Surg Oncol 110:15–20
St John ER, Al-Khudairi R, Ashrafian H et al (2017) Diagnostic accuracy of intraoperative techniques for MA in breast cancer surgery a meta-analysis. Ann Surg 265:300–310
Maloney David M, McClatchy Brian W, Pogue Keith D, Paulsen Wendy A, Wells Richard J, Barth BW, Benjamin Maloney JW, McClatchy DM et al (2018) Review of methods for intraoperative margin detection for breast conserving surgery. J Biomed Opt 23:100901
Nunez A, Jones V, Schulz-Costello K, Schmolze D (2020) Accuracy of gross intraoperative MA for breast cancer: experience since the SSO-ASTRO margin consensus guidelines.
Namdar ZM, Omidifar N, Arasteh P et al (2021) How accurate is frozen section pathology compared to permanent pathology in detecting involved margins and lymph nodes in breast cancer? World J Surg Oncol 19:1–7
Boughey JC, Keeney GL, Radensky P et al (2016) Economic implications of widespread expansion of frozen section margin analysis to guide surgical resection in women with breast cancer undergoing breast-conserving surgery. J Oncol Pract 12:e413–e422
Agarwal G, Chaitra S, Sabaretnam M et al (2018) Intraoperative margin assessment by frozen section enables cost-effective, safe, one-step breast conservation. J Glob Oncol 4:2s–2s
Omidifar N, Chogani E, Zangouri V, et al (2022) Cost-effectiveness analysis of intraoperative frozen section in women with breast cancer: evidence from South of Iran. 47
Acknowledgements
The authors acknowledge the help received from Dr Amulya Cherukumudi from Sri Jayadeva Institute of Cardiovascular Science and Research, Bengaluru in statistical analysis of data, and the contributions from staff of the Department of Endocrine and Breast Surgery, SGPGIMS, Lucknow for their help and support.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
No conflicts of interest.
Informed consent for participants
Waiver of consent approved by ethics committee.
Ethics approval
Institutional ethics committee clearance reference no. 2021–102-MCh-EXP-38.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.
About this article
Cite this article
Agarwal, G., Sattavan, S., Vishvak Chanthar, K.M.M. et al. Cost-Efficacy Analysis of Use of Frozen Section Histology for Margin Assessment During Breast Conservation Surgery in Breast Cancer Patients. World J Surg 47, 2457–2463 (2023). https://doi.org/10.1007/s00268-023-07094-2
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00268-023-07094-2