Advertisement

Annals of Surgical Oncology

, Volume 25, Issue 9, pp 2573–2578 | Cite as

Surgeon Variability and Factors Predicting for Reoperation Following Breast-Conserving Surgery

  • Monica G. Valero
  • Melissa Anne Mallory
  • Katya Losk
  • Mustafa Tukenmez
  • Jaeho Hwang
  • Kristen Camuso
  • Craig Bunnell
  • Tari King
  • Mehra GolshanEmail author
Breast Oncology

Abstract

Background

Reoperation after breast-conserving surgery (BCS) is common and has been partially associated with the lack of consensus on margin definition. We sought to investigate factors associated with reoperations and variation in reoperation rates across breast surgeons at our cancer center.

Methods

Retrospective analyses of patients with clinical stage I–II breast cancer who underwent BCS between January and December 2014 were conducted prior to the recommendation of ‘no ink on tumor’ margin. Patient demographics and tumor and surgical data were extracted from medical records. A multivariate regression model was used to identify factors associated with reoperation.

Results

Overall, 490 patients with stage I (n  = 408) and stage II (n  = 89) breast cancer underwent BCS; seven patients had bilateral breast cancer and underwent bilateral BCS procedures. Median invasive tumor size was 1.1 cm, reoperation rate was 22.9% (n  = 114) and varied among surgeons (range 15–40%), and, in 100 (88%) patients, the second procedure was re-excision, followed by unilateral mastectomy (n  = 7, 6%) and bilateral mastectomy (n  = 7, 6%). Intraoperative margin techniques (global cavity or targeted shaves) were utilized in 50.1% of cases, while no specific margin technique was utilized in 49.9% of cases. Median total specimen size was 65.8 cm3 (range 24.5–156.0). In the adjusted model, patients with multifocal disease were more likely to undergo reoperation [odds ratio (OR) 5.78, 95% confidence interval (CI) 2.17–15.42]. In addition, two surgeons were found to have significantly higher reoperation rates (OR 6.41, 95% CI 1.94–21.22; OR 3.41, 95% CI 1.07–10.85).

Conclusions

Examination of BCS demonstrated variability in reoperation rates and margin practices among our breast surgeons. Future trials should look at surgeon-specific factors that may predict for reoperations.

Notes

Funding

This study was funded in part by National Institutes of Health (NIH) Grant R25CA089017 and the Breast Cancer Research Foundation.

Disclosure

Monica G. Valero, Melissa Anne Mallory, Katya Losk, Mustafa Tukenmez, Jaeho Hwang, Kristen Camuso, Craig Bunnell, Tari King, and Mehra Golshan have no conflict of interests to declare.

References

  1. 1.
    Cody HS 3rd, Van Zee KJ. Reexcision: the other breast cancer epidemic. N Engl J Med 2015;373:568–9.CrossRefPubMedGoogle Scholar
  2. 2.
    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;347:1227–32.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Early Breast Cancer Trialists’ Collaborative Group, Clarke M, Collins R, et al. Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;366:2087–106.CrossRefGoogle Scholar
  4. 4.
    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;347:1233–41.CrossRefPubMedGoogle Scholar
  5. 5.
    Fleming FJ, Hill AD, Mc Dermott EW, O’Doherty A, O’Higgins NJ, Quinn CM. Intraoperative margin assessment and re-excision rate in breast conserving surgery. Eur J Surg Oncol 2004;30:233–7.CrossRefPubMedGoogle Scholar
  6. 6.
    Bani MR, Lux MP, Heusinger K, et al. Factors correlating with reexcision after breast-conserving therapy. Eur J Surg Oncol 2009;35:32–7.CrossRefPubMedGoogle Scholar
  7. 7.
    McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. JAMA 2012;307:467–75.CrossRefPubMedGoogle Scholar
  8. 8.
    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
  9. 9.
    Kobbermann A, Unzeitig A, Xie XJ, et al. Impact of routine cavity shave margins on breast cancer re-excision rates. Ann Surg Oncol 2011;18:1349–55.CrossRefPubMedGoogle Scholar
  10. 10.
    Sabel MS, Rogers K, Griffith K, et al. Residual disease after re-excision lumpectomy for close margins. J Surg Oncol 2009;99:99–103.CrossRefPubMedGoogle Scholar
  11. 11.
    Wilke LG, Czechura T, Wang C, Lapin B, Liederbach E, Winchester DP, et al. Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004–2010. JAMA Surg 2014;149:1296–305.CrossRefPubMedGoogle Scholar
  12. 12.
    Deutsch M, Flickinger JC. Patient characteristics and treatment factors affecting cosmesis following lumpectomy and breast irradiation. Am J Clin Oncol 2003;26:350–3.PubMedGoogle Scholar
  13. 13.
    Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmillan RD. Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. Br J Surg 2003;90:1505–09.CrossRefPubMedGoogle Scholar
  14. 14.
    Heil J, Breitkreuz K, Golatta M, et al. Do reexcisions impair aesthetic outcome in breast conservation surgery? Exploratory analysis of a prospective cohort study. Ann Surg Oncol 2012;19:541–7.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.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Wazer DE, Schmidt-Ullrich RK, Ruthazer R, DiPetrillo T, Boyle T, Kanski J, et al. The influence of age and extensive intraductal component histology upon breast lumpectomy margin assessment as a predictor of residual tumor. Int J Radiat Oncol Biol Phys 1999;45:885–91.CrossRefPubMedGoogle Scholar
  17. 17.
    Singletary SE. Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy. Am J Surg 2002;184:383–93.CrossRefPubMedGoogle Scholar
  18. 18.
    Aziz D, Rawlinson E, Narod SA, Sun P, Lickley HL, McCready DR, et al. The role of reexcision for positive margins in optimizing local disease control after breast-conserving surgery for cancer. Breast J 2006;12:331–7.CrossRefPubMedGoogle Scholar
  19. 19.
    Rutter CE, Park HS, Killelea BK, Evans SB. Growing Use of Mastectomy for Ductal Carcinoma-In Situ of the Breast Among Young Women in the United States. Ann Surg Oncol 2015;22:2378–86.CrossRefPubMedGoogle Scholar
  20. 20.
    Pesce CE, Liederbach E, Czechura T, Winchester DJ, Yao K. Changing surgical trends in young patients with early stage breast cancer, 2003 to 2010: a report from the National Cancer Data Base. J Am Coll Surg 2014;219:19–28.CrossRefPubMedGoogle Scholar
  21. 21.
    Staradub VL, Hsieh YC, Clauson J, Langerman A, Rademaker AW, Morrow M. Factors that influence surgical choices in women with breast carcinoma. Cancer 2002;95:1185–90.CrossRefPubMedGoogle Scholar
  22. 22.
    Schifano P, Scarinci M, Borgia P, Perucci CA. Analysis of the recourse to conservative surgery in the treatment of breast tumors. Tumori 2002;88:131–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Jung W, Kang E, Kim SM, et al. Factors Associated with Re-excision after Breast-Conserving Surgery for Early-Stage Breast Cancer. J Breast Cancer 2012;15:412–9.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Kurniawan ED, Wong MH, Windle I, et al. Predictors of surgical margin status in breast-conserving surgery within a breast screening program. Ann Surg Oncol 2008;15:2542–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Schiller DE, Le LW, Cho BC, Youngson BJ, McCready DR. Factors associated with negative margins of lumpectomy specimen: potential use in selecting patients for intraoperative radiotherapy. Ann Surg Oncol 2008;15:833–42.CrossRefPubMedGoogle Scholar
  26. 26.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    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. Int J Radiat Oncol Biol Phys 2014;88:553–64.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    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

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Monica G. Valero
    • 1
    • 2
  • Melissa Anne Mallory
    • 1
    • 2
  • Katya Losk
    • 3
  • Mustafa Tukenmez
    • 1
  • Jaeho Hwang
    • 2
  • Kristen Camuso
    • 3
  • Craig Bunnell
    • 2
    • 3
  • Tari King
    • 1
    • 2
  • Mehra Golshan
    • 1
    • 2
    Email author
  1. 1.Department of SurgeryBrigham and Women’s Hospital and Dana Farber Cancer InstituteBostonUSA
  2. 2.Harvard Medical SchoolBostonUSA
  3. 3.Department of Medical OncologyDana Farber Cancer InstituteBostonUSA

Personalised recommendations