Advertisement

Annals of Surgical Oncology

, Volume 23, Issue 10, pp 3239–3246 | Cite as

Early Adoption of the SSO-ASTRO Consensus Guidelines on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Stage I and II Invasive Breast Cancer: Initial Experience from Memorial Sloan Kettering Cancer Center

  • Laura H. Rosenberger
  • Anita Mamtani
  • Sarah Fuzesi
  • Michelle Stempel
  • Anne Eaton
  • Monica Morrow
  • Mary L. GemignaniEmail author
Breast Oncology

Abstract

Background

Reexcision rates in patients undergoing breast-conserving surgery (BCS) for early-stage invasive breast cancer are highly variable. The Society of Surgical Oncology (SSO) and American Society for Radiation Oncology (ASTRO) published consensus guidelines to help standardize practice. We sought to determine reexcision rates before and after guideline adoption at our institution.

Methods

We identified patients with stage I or II invasive breast cancer initially treated with BCS between June 1, 2013, and October 31, 2014. Margins were defined as positive (tumor on ink), close (≤1 mm), or negative (>1 mm), and were recorded for both invasive cancer and ductal carcinoma-in situ (DCIS) components. Reexcision rates were quantified, characteristics were compared between groups, and multivariable logistic regression was performed.

Results

A total of 1205 patients were identified, 504 before and 701 after the guideline adoption (January 1, 2014). Clinical and pathologic characteristics were similar between time periods. Reexcision rates significantly declined from 21.4 to 15.1 % (p = 0.006) after guideline adoption. A multivariable model identified extensive intraductal component (odds ratio [OR] 2.5, 95 % confidence interval [CI] 1.2–5.2), multifocality (OR 2.0, 95 % CI 1.2–3.6), positive (OR 844.4, 95 % CI 226.3–5562.5) and close (OR 38.3, 95 % CI 21.5–71.8) ductal carcinoma-in situ margin, positive (OR 174.2, 95 % CI 66.2–530.0) and close (OR 6.4, 95 % CI 3.0–13.6) invasive margin, and time period (OR 0.5, 95 % CI 0.3–0.9 for post vs. pre) as independently associated with reexcision.

Conclusions

Overall reexcision rates declined significantly after guideline adoption. Close invasive margins were associated with higher rates of reexcision than negative invasive margins in both time periods; however, the effect diminished in the postguideline adoption period. Thus, we expect continued decline in reexcision rates as adherence to guidelines becomes more uniform.

Keywords

Invasive Breast Cancer Negative Margin Ipsilateral Breast Tumor Recurrence Invasive Margin Extensive Intraductal Component 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgment

This study was funded in part by NIH/NCI Cancer Center Support Grant P30 CA008748.

Disclosure

The authors declare no conflict of interest.

References

  1. 1.
    Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M. What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol. 2010;17:558–63.CrossRefPubMedGoogle Scholar
  2. 2.
    McCahill LE, Privette A, James T, et al. Quality measures for breast cancer surgery: initial validation of feasibility and assessment of variation among surgeons. Arch Surg. 2009;144:455–62.CrossRefPubMedGoogle Scholar
  3. 3.
    McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. JAMA. 2012;307:467–75.CrossRefPubMedGoogle Scholar
  4. 4.
    Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009;302:1551–6.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    King TA, Sakr R, Patil S, et al. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol. 2011;29:2158–64.CrossRefPubMedGoogle Scholar
  6. 6.
    Moran MS, Schnitt SJ, Giuliano AE, et al. 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. Ann Surg Oncol. 2014;21:704–16.CrossRefPubMedGoogle Scholar
  7. 7.
    Chagpar AB, Killelea BK, Tsangaris TN, et al. A randomized, controlled trial of cavity shave margins in breast cancer. N Engl J Med. 2015;373:503–10.CrossRefPubMedGoogle Scholar
  8. 8.
    Corben AD, Morrow M. Margins in breast cancer surgery. In: El-Tamer MB, editor. Principles and techniques in oncoplastic breast cancer surgery. Singapore: World Scientific Publishing; 2012. p. 65–85.CrossRefGoogle Scholar
  9. 9.
    Moo TA, Choi L, Culpepper C, et al. Impact of margin assessment method on positive margin rate and total volume excised. Ann Surg Oncol. 2014;21:86–92.CrossRefPubMedGoogle Scholar
  10. 10.
    DeSnyder SM, Hunt KK, Smith BD, Moran MS, Klimberg S, Lucci A. Assessment of practice patterns following publication of the SSO-ASTRO consensus guideline on margins for breast-conserving therapy in stage I and II invasive breast cancer. Ann Surg Oncol. 2015;22:3250–6.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Holland R, Connolly JL, Gelman R, et al. The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast. J Clin Oncol. 1990;8:113–8.PubMedGoogle Scholar
  12. 12.
    Schnitt SJ, Connolly JL, Harris JR, Hellman S, Cohen RB. Pathologic predictors of early local recurrence in Stage I and II breast cancer treated by primary radiation therapy. Cancer. 1984;53:1049–57.CrossRefPubMedGoogle Scholar
  13. 13.
    Schnitt SJ, Abner A, Gelman R, et al. The relationship between microscopic margins of resection and the risk of local recurrence in patients with breast cancer treated with breast-conserving surgery and radiation therapy. Cancer. 1994;74:1746–51.CrossRefPubMedGoogle Scholar
  14. 14.
    Houssami N, Macaskill P, Marinovich ML, et al. Meta-analysis of the impact of surgical margins on local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy. Eur J Cancer. 2010;46:3219–32.CrossRefPubMedGoogle Scholar
  15. 15.
    Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2014;21:717–30.CrossRefPubMedGoogle Scholar
  16. 16.
    Pilewskie M, Ho A, Orell E, et al. Effect of margin width on local recurrence in triple-negative breast cancer patients treated with breast-conserving therapy. Ann Surg Oncol. 2014;21:1209–14.CrossRefPubMedGoogle Scholar
  17. 17.
    Hadzikadic Gusic L, McGuire KP, Ozmen T, et al. Margin width is not predictive of residual disease on re-excision in breast conserving therapy. J Surg Oncol. 2014;109:426–30.CrossRefPubMedGoogle Scholar
  18. 18.
    O’Brien J, Morrow M. Margin width is not predictive of residual disease on re-excision in breast-conserving therapy. J Surg Oncol. 2014;109:507–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Russo AL, Arvold ND, Niemierko A, et al. Margin status and the risk of local recurrence in patients with early-stage breast cancer treated with breast-conserving therapy. Breast Cancer Res Treat. 2013;140:353–61.CrossRefPubMedGoogle Scholar
  20. 20.
    Isaacs AJ, Gemignani ML, Pusic A, Sedrakyan A. Association of breast conservation surgery for cancer with 90-day reoperation rates in New York State. JAMA Surg. 2015. doi: 10.1001/jamasurg.2015.5535.Google Scholar
  21. 21.
    Nag U, Hwang ES. Reoperation for margins after breast conservation surgery: what’s old is new again. JAMA Surg. 2015. doi: 10.1001/jamasurg.2015.5555.Google Scholar

Copyright information

© Society of Surgical Oncology 2016

Authors and Affiliations

  • Laura H. Rosenberger
    • 1
  • Anita Mamtani
    • 1
  • Sarah Fuzesi
    • 1
  • Michelle Stempel
    • 1
  • Anne Eaton
    • 2
  • Monica Morrow
    • 1
  • Mary L. Gemignani
    • 1
    Email author
  1. 1.Breast Service, Department of SurgeryMemorial Sloan Kettering Cancer CenterNew YorkUSA
  2. 2.Department of Epidemiology and BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkUSA

Personalised recommendations