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JAMA Oncol. 2017 Oct 1;3(10):1352-1357. doi: 10.1001/jamaoncol.2017.0774.

Trends in Reoperation After Initial Lumpectomy for Breast Cancer: Addressing Overtreatment in Surgical Management.

Author information

1
Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
2
School of Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor.
3
Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Service Center of Innovation, Ann Arbor, Michigan.
4
Department of Epidemiology, Emory University, Rollins School of Public Health, Atlanta, Georgia.
5
Keck School of Medicine, Department of Preventive Medicine, University of Southern California, Los Angeles.
6
Departments of Medicine and Health Research and Policy, Stanford University, Stanford, California.
7
School of Public Health, Department of Health Management and Policy, University of Michigan, Ann Arbor.
8
School of Medicine, Department of Radiation Oncology, University of Michigan, Ann Arbor.

Abstract

Importance:

Surgery after initial lumpectomy to obtain more widely clear margins is common and may lead to mastectomy.

Objective:

To describe surgeons' approach to surgical margins for invasive breast cancer, and changes in postlumpectomy surgery rates, and final surgical treatment following a 2014 consensus statement endorsing a margin of "no ink on tumor."

Design, Setting, and Participants:

This was a population-based cohort survey study of 7303 eligible women ages 20 to 79 years with stage I and II breast cancer diagnosed in 2013 to 2015 and identified from the Georgia and Los Angeles County, California, Surveillance, Epidemiology, and End Results registries. A total of 5080 (70%) returned a survey. Those with bilateral disease, missing stage or treatment data, and with ductal carcinoma in situ were excluded, leaving 3729 patients in the analytic sample; 98% of these identified their attending surgeon. Between April 2015 and May 2016, 488 surgeons were surveyed regarding lumpectomy margins; 342 (70%) responded completely. Pathology reports of all patients having a second surgery and a 30% sample of those with 1 surgery were reviewed. Time trends were analyzed with multinomial regression models.

Main Outcomes and Measures:

Rates of final surgical procedure (lumpectomy, unilateral mastectomy, bilateral mastectomy) and rates of additional surgery after initial lumpectomy over time, and surgeon attitudes toward an adequate lumpectomy margin.

Results:

The 67% rate of initial lumpectomy in the 3729 patient analytic sample was unchanged during the study. The rate of final lumpectomy increased by 13% from 2013 to 2015, accompanied by a decrease in unilateral and bilateral mastectomy (P = .002). Surgery after initial lumpectomy declined by 16% (P < .001). Pathology review documented no significant association between date of treatment and positive margins. Of 342 responding surgeons, 69% endorsed a margin of no ink on tumor to avoid reexcision in estrogen receptor-positive progesterone receptor-positive cancer and 63% for estrogen receptor-negative progesterone- receptor-negative cancer. Surgeons treating more than 50 breast cancers annually were significantly more likely to report this margin as adequate (85%; n = 105) compared with those treating 20 cases or fewer (55%; n = 131) (P < .001).

Conclusions and Relevance:

Additional surgery after initial lumpectomy decreased markedly from 2013 to 2015 concomitant with dissemination of clinical guidelines endorsing a minimal negative margin. These findings suggest that surgeon-led initiatives to address potential overtreatment can reduce the burden of surgical management in patients with cancer.

PMID:
28586788
PMCID:
PMC5710510
DOI:
10.1001/jamaoncol.2017.0774
[Indexed for MEDLINE]
Free PMC Article

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