Hospital and surgeon caseload are associated with risk of re-operation following breast-conserving surgery

Is the Number or Proximity of Margins Less than 2 mm Associated with an Increased Mastectomy Rate in Patients Attempting Breast Conservation Therapy for Ductal Carcinoma In Situ?

BACKGROUND

Consensus guidelines recommend ≥ 2 mm margins in patients undergoing partial mastectomy (PM) for ductal carcinoma in situ (DCIS). It is unknown whether the number or proximity of margins less than 2 mm is associated with an increased mastectomy rate in patients attempting breast conservation therapy (BCT) for DCIS. The aim of this study is to examine this relationship.

PATIENTS AND METHODS

An institutional database review identified 208 patients with DCIS who underwent PM at a tertiary referral center and community hospitals from July 2020 to June 2023. Patients with a history of breast cancer, previous surgery for breast cancer, ipsilateral invasive carcinoma, papillary carcinoma, Paget's disease, more lobular carcinoma in situ (LCIS) than DCIS present, initial mastectomy, no DCIS present, routine shave margins (of all vectors), and ≥ 2 mm margins of all six vectors were excluded. Selective intraoperative margin re-excisions were included.

RESULTS

A total of 208 patients who met inclusion criteria were retrospectively reviewed. 122 (25%) had one close/positive (< 2 mm) margin and 86 (18%) had two or more close/positive margins. Of the patients with one close/positive margin, 7% (9/122) eventually underwent mastectomy. Of the patients with two or more close/positive margins, 20% (17/86) eventually underwent mastectomy. Overall, no patients with opposing margins underwent mastectomy.

CONCLUSIONS

Patients undergoing PM for DCIS have a mastectomy rate that is increased threefold, with two or more close/positive margins at initial PM, when compared with those with only one close/positive margin. The presence of opposing close/positive margins at initial PM did not increase the mastectomy rate and most were cleared with re-excision.

Clinicopathological Predictors of Positive Resection Margins in Breast-Conserving Surgery

BACKGROUND

Ductal carcinoma in situ (DCIS) is associated with risk of positive resection margins following breast-conserving surgery (BCS) and subsequent reoperation. Prior reports grossly underestimate the risk of margin positivity with IBC containing a DCIS component (IBC + DCIS) due to patient-level rather than margin-level analysis.

OBJECTIVE

The aim of this study was to delineate the relative risk of IBC + DCIS compared with pure IBC (without a DCIS component) on margin positivity through detailed margin-level interrogation.

METHODS

A single institution, retrospective, observational cohort study was conducted in which pathology databases were evaluated to identify patients who underwent BCS over 5 years (2014-2019). Margin-level interrogation included granular detail into the extent, pathological subtype and grade of disease at each resection margin. Predictors of a positive margin were computed using multivariate regression analysis.

RESULTS

Clinicopathological details were examined from 5454 margins from 909 women. The relative risk of a positive margin with IBC + DCIS versus pure IBC was 8.76 (95% confidence interval [CI] 6.64-11.56) applying UK Association of Breast Surgery guidelines, and 8.44 (95% CI 6.57-10.84) applying the Society of Surgical Oncology/American Society for Radiation Oncology guidelines. Independent predictors of margin positivity included younger patient age (0.033, 95% CI 0.006-0.060), lower specimen weight (0.045, 95% CI 0.020-0.069), multifocality (0.256, 95% CI 0.137-0.376), lymphovascular invasion (0.138, 95% CI 0.068-0.208) and comedonecrosis (0.113, 95% CI 0.040-0.185).

CONCLUSIONS

Compared with pure IBC, the relative risk of a positive margin with IBC + DCIS is approximately ninefold, significantly higher than prior estimates. This margin-level methodology is believed to represent the impact of DCIS more accurately on margin positivity in IBC.

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

Lowering Re-excision Rates After Breast-Conserving Surgery: Unraveling the Intersection Between Surgeon Case Volumes and Techniques

BACKGROUND

The re-excision rates after breast-conserving surgery (BCS) are significantly varied, with surgeon case volume as one influential factor. Surgeons with higher case volumes have been shown to have lower reoperation rates. This study attempted to determine whether this may be attributable to excessive breast tissue removal during initial BCS.

METHODS

A retrospective study analyzed referrals to the authors' cancer center during 3 years. Patients undergoing initial BCS for ductal carcinoma in situ or T1-T3 breast cancers were included. Patient age, tumor factors, surgeon case volume, and the calculated resection ratio (CRR) were analyzed. The total resection volume was divided by the optimal resection volume to produce the CRR, which reflected the magnitude of excess tissue resected during initial BCS. Comparison of the mean CRR between surgeon case-volume categories was performed with a repeated measures analysis of variance. A multivariate regression model assessed the effects of the CRR and surgeon case volume on re-excision rates.

RESULTS

Larger tumor size, lobular histology, and lower CRR were associated with increased re-excision rates. The CRR was similar for each surgeon case-volume group. Surgeon case volume was not independently associated with re-excision rates, but surgeons with very high case volumes had lower odds of re-excision than surgeons with intermediate case volumes (odds ratio 0.44; 95% confidence interval 0.21-0.91).

CONCLUSIONS

When control was used for the CRR, apparent differences in re-excision rates between surgeon case-volume groups were observed, suggesting that surgeons with higher case volumes may be more accurate when performing BCS.

The requirements of a specialist breast centre

This article is an update of the requirements of a specialist breast centre, produced by EUSOMA and endorsed by ECCO as part of Essential Requirements for Quality Cancer Care (ERQCC) programme, and ESMO. To meet aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this article, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Impact of SSO-ASTRO margin guidelines on reoperation rates following breast-conserving surgery

BACKGROUND

Re-operation rates following breast-conserving surgery (BCS) for early invasive breast cancer are highly variable, largely due to uncertainty regarding adequate margins. The 2014 SSO-ASTRO guidelines recommended "no ink on tumor" as adequate margins. We evaluated the effect of guideline implementation on re-operation following BCS at our regional cancer center.

METHODS

Retrospective chart review was performed on records for patients with early invasive breast carcinoma undergoing BCS between February 2011 and May 2017. Time period, pathologic margin status, patient and tumor characteristics were assessed for their impact on re-operation rates.

RESULTS

Overall re-operation rate decreased following the guidelines release (OR 0.28, 95% C.I. 0.15-0.51, p = <0.0001), with an unadjusted decrease of 3.89%. Re-operations on both close (OR 0.17, 95% C.I. 0.07-0.40, p = <0.0001) and widely negative (OR 0.20, 95% C.I. 0.05-0.77, p = 0.02) margins decreased in the post-guidelines time period.

CONCLUSION

SSO-ASTRO margins guideline release was associated with decreased re-operation. Furthermore, re-operations rates decreased in patients with pathologically negative margins, the target population the guidelines were meant to address.

Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data

OBJECTIVES

To investigate between-hospital variation in the probability of reoperation within 90 days of initial breast-conserving surgery (BCS), and the contribution of health system-level and other factors.

DESIGN

Population-based, retrospective cohort study.

SETTING

New South Wales (NSW), Australia.

PARTICIPANTS

Linked administrative hospitalisation data were used to define a cohort of adult women undergoing initial BCS for breast cancer in NSW between 1 July 2002 and 31 December 2013.

PRIMARY OUTCOME MEASURES

Multilevel, cross-classified models with patients clustered within hospitals and residential areas were used to examine factors associated with any reoperation, and either re-excision or mastectomy, within 90 days.

RESULTS

Of 34 458 women undergoing BCS, 29.1% underwent reoperation within 90 days, half of which were mastectomies. Overall, the probability of reoperation decreased slightly over time. However, there were divergent patterns by reoperation type; the probability of re-excision increased alongside a concomitant decrease in the probability of mastectomy. Significant between-hospital variation was observed. Non-metropolitan location and surgery at low-volume hospitals were associated with a higher overall probability of reoperation, and of mastectomy specifically, after accounting for patient-level factors, calendar year and area-level socioeconomic status. The magnitude of association with geographical location and surgical volume decreased over time.

CONCLUSIONS

Reoperation rates within 90 days of BCS varied significantly between hospitals. For women undergoing mastectomy after BCS, this represents a dramatic change in clinical course. Multilevel modelling suggests unwarranted clinical variation may be an issue, likely due to disparities in access to multidisciplinary breast cancer care and preoperative diagnostic procedures. However, the observed reduction in disparities over time is encouraging and indicates that guidelines and policy initiatives have the potential to improve regional breast cancer care.

Re-excision and survival following breast conserving surgery in early stage breast cancer patients: a population-based study

Background

Increasing population-based evidence suggests that patients who receive breast conserving surgery (BCS) plus radiotherapy have superior survival than those who receive mastectomy. It is unclear, however, how BCS followed by re-excision is associated with all-cause and breast cancer-specific mortality, and whether the BCS survival advantage is maintained if re-excision is needed. The aim of this study was to investigate the clinical, patient, provider and geographic variation associated with receipt of re-excision surgery, and to examine the relationship between re-excision and all-cause and breast cancer-specific mortality.

Methods

All women diagnosed with stage I-III breast cancer in Alberta, Canada from 2002 to 2009 were identified from the Alberta Cancer Registry, of which 11,626 were eligible for study inclusion. Type of first breast cancer surgery after diagnosis, subsequent re-excisions within 1 year, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate the adjusted odds ratios of re-excision by the factors of interest. Poisson regression models were fitted to compare all-cause and breast cancer-specific mortality by surgical pattern.

Results

Re-excision surgery was received by 19% (N = 5659) of patients who initially received BCS. The adjusted odds of re-excision varied significantly by geography of surgery, and by individual surgeon among stage I and II patients beyond the variation explained by the factors investigated (Stage I OR standard deviation (SD) = 0.43; stage II OR SD = 0.39). Patients who were treated with BCS plus re-excision surgery with either mastectomy or further BCS had similar all-cause and breast cancer-specific mortality as those treated with BCS without re-excision.

Conclusion

These results suggest that breast cancer patients who are treated with BCS plus re-excision surgery by either mastectomy or further BCS have similar survival as those treated with BCS without re-excision. The significant variation in the likelihood of re-excision by geography and by individual surgeon is concerning, especially given the costs to the patient associated with additional surgery and the financial costs to the health system.

Reoperation costs in attempted breast-conserving surgery: a decision analysis

BACKGROUND

Breast-conserving surgery (bcs) is the preferred surgical approach for most patients with early-stage breast cancer. Frequently, concerns arise about the pathologic margin status, resulting in an average reoperation rate of 23% in Canada. No consensus has been reached about the ideal reoperation rate, although 10% has been suggested as a target. Upon undergoing reoperation, many patients choose mastectomy and breast reconstruction, which add to the morbidity and cost of patient care. We attempted to identify the cost of reoperation after bcs, and the effect that a reduction in the reoperation rate could have on the B.C. health care system.

METHODS

A decision tree was constructed to estimate the average cost per patient undergoing initial bcs with two reoperation frequency scenarios: 23% and 10%. The model included the direct medical costs from the perspective of the B.C. health care system for the most common surgical treatment options, including breast reconstruction and postoperative radiation therapy.

RESULTS

Costs ranged from a low of $8,225 per patient with definitive bcs [95% confidence interval (ci): $8,061 to $8,383] to a high of $26,026 for reoperation with mastectomy and delayed reconstruction (95% ci: $23,991 to $28,122). If the reoperation rate could be reduced to 10%, the average saving would be $1,055 per patient undergoing attempted bcs (95% ci: $959 to $1,156). If the lower rate were to be achieved in British Columbia, it would translate into a savings of $1.9 million annually.

SUMMARY

The implementation of initiatives to reduce reoperation after bcs could result in significant savings to the health care system, while potentially improving the quality of patient care.

Surgeon Volume, Patient Age, and Tumor-Related Factors Influence the Need for Re-Excision After Breast-Conserving Surgery

BACKGROUND

Breast-conserving surgery (BCS) is the preferred surgical approach for the majority of patients with early-stage breast cancer. There are frequent issues regarding pathologic margin status, requiring margin re-excision, and, in the literature, there is significant variability in re-excision rates, suggesting this is a potential quality-of-care issue. Understanding the patient-, disease-, and physician-related factors influencing reoperation rates is of importance in an effort to minimize this occurrence.

METHODS

A retrospective analysis of all patients referred to our cancer center over a 3-year period (1 January 2011-31 December 2013) was performed. Surgeon volume, and patient- and tumor-related factors were assessed for their impact on re-excision rates. Multivariate logistic regression analysis was performed to identify variables of significance influencing reoperation rates after attempted BCS.

RESULTS

Overall, 594 patients underwent initial BCS, with 159 (26.8%) patients requiring at least one re-excision to ensure negative pathologic margins. On multivariate analysis, low surgeon case volume, patient age (under 46 years of age), tumor size (>2 cm), and lobular carcinoma were associated with an increased re-excision rate.

CONCLUSION

Re-excisions are frequent after BCS and are influenced by surgeon volume, patient age, and tumor-related factors. These factors should be considered when counseling patients considering BCS, and also for quality assurance.

Using Multilevel Models to Explain Variation in Clinical Practice: Surgeon Volume and the Surgical Treatment of Breast Cancer

PURPOSE

To investigate the relationship between surgeon caseload and surgery type, and variation in the surgical treatment of early stage breast cancer patients in Alberta, Canada.

METHODS

All women diagnosed with stage I to III breast cancer in Alberta from 2002 to 2010 were identified from the Alberta Cancer Registry. Type of surgery, surgeon (anonymized), and hospital were obtained from provincial physician claims data. Multilevel logistic regression with surgeons and hospitals as crossed random effects was used to estimate adjusted odds ratios (OR) of receiving mastectomy by surgeon volume. Empirical Bayes estimation was used to estimate adjusted OR for individual surgeons and hospitals.

RESULTS

Mastectomy was found to be inversely related to surgeon volume among stage I and II patients. Patients whose surgery was conducted by a low-volume surgeon had twice the odds of receiving mastectomy as those that had surgery performed by a very high-volume surgeon (stage I OR 2.36, 95 % confidence interval 1.40, 3.97; stage II OR 1.96, 95 % confidence interval 1.13, 3.42). OR of mastectomy varied widely by individual surgeon beyond the variation explained by the factors investigated.

CONCLUSIONS

Surgeon characteristics, including surgeon volume, are associated with surgery type received by breast cancer patients in Alberta. Significant variation in the likelihood of breast-conserving surgery (BCS) by surgeon is concerning given the potential benefits of BCS for those who are eligible.

Which women with breast cancer do, and do not, undergo receptor status testing? A population-based study

INTRODUCTION

Receptor status determines of breast cancer treatment and prognosis. In a population-based study, we investigated predictors of receptor test receipt.

MATERIALS AND METHODS

Invasive breast cancers diagnosed 2006-2008 were abstracted from the National Cancer Registry Ireland. Modified Poisson regression with robust error variance was used to identify socio-demographic, health service and clinical predictors of not undergoing ER, PR or HER2 testing.

RESULTS

7619 breast cancers were included. 7% were not tested for any receptor. 92%, 80% and 86% had oestrogen (ER), progesterone (PR) and human epidermal growth factor 2 (HER2) tests, respectively; 73% were tested for all three. For all three tests, unmarried women were significantly less likely to be tested than married women. Current smokers significantly more often had ER and PR tests. Women treated in a high-volume hospital significantly more often had ER and HER2 tests.

CONCLUSION

After adjusting for clinical factors, socio-demographic and service-related factors significantly predicted receptor test receipt. Some factors deserve further investigation, especially marital status. In the interests of equity, the reasons underlying these associations should be further investigated.

Increased Risk of Surgical Site Infection Among Breast-Conserving Surgery Re-excisions

PURPOSE

The aim of this study was to determine the risk of surgical site infection (SSI) after primary breast-conserving surgery (BCS) versus re-excision among women with carcinoma in situ or invasive breast cancer.

METHODS

We established a retrospective cohort of women aged 18-64 years with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure or Current Procedural Terminology, 4th edition (CPT-4) codes for BCS from 29 June 2004 to 31 December 2010. Prior insurance plan enrollment of at least 180 days was required to establish the index BCS; subsequent re-excisions within 180 days were identified. SSIs occurring 2-90 days after BCS were identified by ICD-9-CM diagnosis codes. The attributable surgery was defined based on SSI onset compared with the BCS date(s). A χ (2) test and generalized estimating equations model were used to compare the incidence of SSI after index and re-excision BCS procedures.

RESULTS

Overall, 23,001 women with 28,827 BCSs were identified; 23.2 % of women had more than one BCS. The incidence of SSI was 1.82 % (418/23,001) for the index BCS and 2.44 % (142/5,826) for re-excision BCS (p = 0.002). The risk of SSI after re-excision remained significantly higher after accounting for multiple procedures within a woman (odds ratio 1.34, 95 % confidence interval 1.07-1.68).

CONCLUSIONS

Surgeons need to be aware of the increased risk of SSI after re-excision BCS compared with the initial procedure. Our results suggest that risk adjustment of SSI rates for re-excision would allow for better comparison of BCS SSI rates between institutions.

Morbidity and mortality in patients with esophageal atresia

BACKGROUND

This study reports national estimates of population characteristics and outcomes for patients with esophageal atresia with or without tracheoesophageal fistula (EA/TEF) and evaluates the relationships between hospital volume and outcomes.

METHODS

Patients admitted within 30 days of life who had International Classification of Diseases, 9th Edition, Clinical Modification diagnosis and procedure codes relevant to EA/TEF during 1999-2012 were identified with the Pediatric Health Information System database. Baseline demographics, comorbidities, and postoperative outcomes, including predictors of in-hospital mortality, were examined up to 2 years after EA/TEF repair.

RESULTS

We identified 3,479 patients with EA/TEF treated at 43 children's hospitals; 37% were premature and 83.5% had ≥1 additional congenital anomaly, with cardiac anomalies (69.6%) being the most prevalent. Within 2 years of discharge, 54.7% were readmitted, 5.2% had a repeat TEF ligation, 11.4% had a repeat operation for their esophageal reconstruction, and 11.7% underwent fundoplication. In-hospital mortality was 5.4%. Independent predictors of mortality included lower birth weight, congenital heart disease, other congenital anomalies, and preoperative mechanical ventilation. There was no relationship between hospital volume and mortality or repeat TEF ligation.

CONCLUSION

This study describes population characteristics and outcomes, including predictors of in-hospital mortality, in EA/TEF patients treated at children's hospitals across the United States. Across these hospitals, rates of mortality or repeat TEF ligation were not dependent on hospital volume.