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Downturn in reoperation after breast conservation surgery

Key clinical point: Rates of reoperation after breast conservation surgery are declining but vary significantly between surgeons.

Major finding: The mean 90-day reoperation rate after breast conservation surgery declined from 39.5% in 2003-2004 to 23.1% in 2011-2013.

Data source: Population-based sample of 89,448 women undergoing primary breast conservation surgery for breast cancer.

Disclosures: Two authors reported involvement with the Food and Drug Administration–funded MDEpiNet Science and Infrastructure Center; no other conflicts of interest were declared.

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Eliminate reoperations with evidence-based approach

The recent Society for Surgical Oncology–American Society for Radiation Oncology (SSO-ASTRO) consensus guidelines encourage the use of “no ink on tumor” as the current standard in an era of multimodal treatment and evolving understanding of tumor biology along with tumor burden.

Dr. E. Shelley Hwang

Establishing a rational, evidence-based approach to reexcision as originally proposed by Fisher et al. and supported by the new SSO-ASTRO guidelines can provide substantial national cost savings by eliminating reexcisions for close but negative margins.

Dr. Uttara Nag and Dr. E. Shelley Hwang are with the department of health policy and management in the department of surgery, Duke University, Durham, N.C. These comments are taken from an editorial (JAMA Surg. 2016 Feb 17. doi:10.1001/jamasurg.2015.5555). No conflicts of interest were declared.


 

FROM JAMA SURGERY

References

Rates of reoperation after breast conservation surgery have declined significantly since 2003, but nearly 25% of women are still undergoing repeat operations, new data suggest.

Researchers analyzed data from a population-based sample of 89,448 women undergoing primary breast conservation surgery for breast cancer in New York State from 2003 to 2013.

According to a study published online Feb.17 in JAMA Surgery, the mean 90-day reoperation rate declined from 39.5% in 2003-2004 to 23.1% in 2011-2013 (P less than .001), with an overall rate of 30.9% for the entire study period.

“We believe that the findings of reduced occurrence of reoperations are encouraging and imply improvements in training and patient selection for BCS,” wrote Abby J. Isaacs of Cornell University, New York, and her coauthors.

Reoperation rates were highest in younger women (37.7%), compared with women aged over 65 years (26.3%).

However, the study also showed that women aged 50-64 years were less likely than were older or younger women to undergo breast conservation surgery, compared with mastectomy as a repeat procedure (JAMA Surg 2016 Feb 17. doi:10.1001/jamasurg.2015.5535).

Breast conservation surgery was more common than was mastectomy as a repeat procedure in women who were white, had commercial insurance, had low comorbidity scores, or had in situ disease.

Researchers observed significant surgeon-level variation in rates of reoperation after breast conservation surgery, which they described as “novel and unprecedented.” The rates of reoperation among surgeons ranged from 0% to nearly 100%.

Overall, the mean rate of reoperation for surgeons was 30.8%, but nearly 20% of surgeons had reoperation rates above 50% and 6.1% had reoperation rates above the 99.8% limits.

Similarly, 6% of surgeons had reoperation rates below the 95% confidence limits and 2.9% were below the 99.8% limits.

Reoperation rates were independently associated with surgical volume; surgeons performing fewer than 14 breast conservation surgery procedures had a mean reoperation rate of 35.2% while those who performed 34 or more procedures had a reoperation rate of 27.5%.

Over the entire study period, the overall rate of breast conservation surgery peaked in 2004 with more than 8,500 cases, then decreased to a mean number of 8,078 for 2011-2013.

The decrease in primary breast conservation surgery was significantly greater in women aged 20-49 years (P less than .001) with 1,416 women in this age group undergoing breast conservation surgery in 2013, compared with 3,644 women aged 65 years or older.

“The reduction in the use of BCS in women younger than 50 years and a corresponding reduction in overall reoperation rates over time implies that surgeons may be selecting more appropriate patients for the procedures,” the authors wrote.

They acknowledged that they did not have access to information on tumor size, grade, and staging, which are variables known to have an important influence on margin rates and reoperation rates. “We believe, however, in the context of physician-level outcomes, that these factors will not bias the results; the recommendation for BCS will be made by surgeons based on their knowledge of the patients’ disease, and we have no reason to believe that unknowable patient characteristics will be unbalanced between surgeons.”

Two authors reported involvement with the Food and Drug Administration–funded MDEpiNet Science and Infrastructure Center; no other conflicts of interest were declared.

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