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Gilmore R, Chen J, Dembinski R, Reissis Y, Milek D, Cadena L, Habibi M. Cost minimization in breast conserving surgery: a comparative study of radiofrequency spectroscopy and full cavity shave margins. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:66. [PMID: 37716980 PMCID: PMC10504787 DOI: 10.1186/s12962-023-00477-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 09/09/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND In an effort to minimize positive margins and subsequent re-excision after breast conserving surgery (BCS), many providers and facilities have implemented either a Full Cavity Shave (FCS) approach or adding the MarginProbe Radiofrequency Spectroscopy System. OBJECTIVE We sought to create a functioning Pro-Forma for use by facilities and payers to evaluate and compare the cost savings of implementing FCS or MarginProbe based on personalized variable inputs. METHODS A decision tree demonstrating three possible surgical pathways, BCS, BCS + FCS, and BCS + MarginProbe was developed with clinical inputs for re-excision rate, mastectomy as 2nd surgery, rate of reconstruction, and rate of 3rd surgery derived by a literature review. A surgical pathway cost formula was created using the decision tree and financial inputs derived by utilizing the nation's largest database of privately billed health insurance claims and Medicare claims data (fairhealth.org). Using the surgical pathway formula and financial inputs, a customizable Pro-Forma was created for immediate cost savings analysis of BCS + FCS and BCS + Marginprobe using variable inputs. Costs are from the perspective of third-party payers. RESULTS Utilizing MarginProbe to reduce re-excisions for positive margins can be associated with better cost-savings than FCS due to the increased pathology processing costs by using an FCS approach. The reduction in re-excision provided by both FCS and MarginProbe offset their increased expense to various degrees with cost savings of each method improving as baseline re-excisions rates increase, until ultimately each may become cost-neutral or cost-prohibitive when compared to BCS alone. Our data suggest that in the privately insured population, MarginProbe provides a cost-savings over BCS alone when baseline re-excision rates are over 20% and that FCS becomes cost-saving when baseline re-excision rates are over 29%. For Medicare patients, MarginProbe provides a cost-savings when baseline re-excision rates exceed 34%, and FCS becomes cost-saving for re-excision rates over 52%. Our Pro-Forma allows an individual provider or institution to evaluate the cost savings of the FCS approach and/or utilization of the MarginProbe device such that the additional cost or cost-savings of utilizing one or both of these methods can be quickly calculated based on their facility's volume and baseline re-excision rate. CONCLUSIONS Our data suggest that utilizing either an FCS approach or the MarginProbe radiofrequency spectroscopy system may be a cost-saving solution to reducing the rate of re-excisions depending on a facility or practice's surgical volume and baseline re-excision rate. The degree to which each of these interventions provides an added cost or cost-savings to healthcare payers can be evaluated by utilizing the Pro-Forma outlined herein with customizable variable inputs.
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Affiliation(s)
- Richard Gilmore
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Jennifer Chen
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Robert Dembinski
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Yannis Reissis
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - David Milek
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Lisa Cadena
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA
| | - Mehran Habibi
- Director, Breast Program at Staten Island University Hospital, Chief of Breast Surgery, Western Region, Northwell Health, 256 Mason Ave., Building B, 2nd Fl., Staten Island, NY, 10305, USA.
- Department of Surgery, Northwell Health, Zucker School of Medicine, New York, United States.
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Chakedis JM, Tang A, Savitz A, Lyon LL, Palacios PE, Vuong B, Kavanagh MA, Kuehner GE, Chang SB. Economic Impact of Reducing Reexcision Rates after Breast-Conserving Surgery in a Large, Integrated Health System. Ann Surg Oncol 2022; 29:6288-6296. [PMID: 35904654 DOI: 10.1245/s10434-022-12127-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/12/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Reexcision after breast-conserving surgery (BCS) is costly for patients, but few studies have captured the economic burden to a healthcare system. We quantified operating room (OR) charges as well as OR time and then modeled expected savings of a reexcision reduction initiative. METHODS We performed a retrospective cohort review of all breast cancer patients with BCS between January 1, 2016 and December 31, 2020. Operating room charges of disposable supplies and implants as well as operative time were calculated. RESULTS During the 5-year period, the 8804 patients who underwent BCS, 1628 (18.5%) required reexcision. The reexcision cohort was younger (61 vs. 64 years, p < 0.001), more likely to have ductal carcinoma in situ (DCIS) (23.7% vs. 15.2%, p < 0.001), and had larger tumors (T1+T2 73.2% vs. 83.1%, p < 0.001). Reexcision costs represented 39% of total costs, the cost per patient for surgery was fourfold higher for reexcision patients. Reexcision operations comprised 14% of total operating room (OR) time (1848 of 13,030 hours). The reexcision rate for 54 surgeons varied from 7.2-39.0% with 46% (n = 25) having a reexcision rate >20%. A model simulating reducing reexcision rates to 20% or below for all surgeons reduced the reexcision rate to 16.2% overall. Using per procedure data, the model predicted a decrease in reexcision operations by 18% (327 operations), OR costs by 14% ($287,534), and OR time by 11% (204 hours). CONCLUSIONS Reexcision after BCS represents 39% of direct OR costs and 14% of OR time in our healthcare system. Modest improvements in surgeon reexcision rates may lead to significant economic and OR time savings.
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Affiliation(s)
- Jeffery M Chakedis
- Department of General Surgery, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Highland Hospital, Oakland, CA, USA
| | - Alison Savitz
- Department of General Surgery, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Liisa L Lyon
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - Patricia E Palacios
- Enterprise Business Services, Kaiser Foundation Health Plan, Oakland, CA, USA
| | - Brooke Vuong
- Department of General Surgery, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Maihgan A Kavanagh
- Department of General Surgery, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Gillian E Kuehner
- Department of General Surgery, The Permanente Medical Group (TPMG), Oakland, CA, USA
| | - Sharon B Chang
- Department of General Surgery, The Permanente Medical Group (TPMG), Oakland, CA, USA. .,Department of Surgery, Kaiser Permanente Medical Center Fremont, Fremont, CA, USA.
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Santilli AML, Ren K, Oleschuk R, Kaufmann M, Rudan J, Fichtinger G, Mousavi P. Application of Intraoperative Mass Spectrometry and Data Analytics for Oncological Margin Detection, A Review. IEEE Trans Biomed Eng 2022; 69:2220-2232. [PMID: 34982670 DOI: 10.1109/tbme.2021.3139992] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE A common phase of early-stage oncological treatment is the surgical resection of cancerous tissue. The presence of cancer cells on the resection margin, referred to as positive margin, is correlated with the recurrence of cancer and may require re-operation, negatively impacting many facets of patient outcomes. There exists a significant gap in the surgeons ability to intraoperatively delineate between tissues. Mass spectrometry methods have shown considerable promise as intraoperative tissue profiling tools that can assist with the complete resection of cancer. To do so, the vastness of the information collected through these modalities must be digested, relying on robust and efficient extraction of insights through data analysis pipelines. METHODS We review clinical mass spectrometry literature and prioritize intraoperatively applied modalities. We also survey the data analysis methods employed in these studies. RESULTS Our review outlines the advantages and shortcomings of mass spectrometry imaging and point-based tissue probing methods. For each modality, we identify statistical, linear transformation and machine learning techniques that demonstrate high performance in classifying cancerous tissues across several organ systems. A limited number of studies presented results captured intraoperatively. CONCLUSION Through continued research of data centric techniques, like mass spectrometry, and the development of robust analysis approaches, intraoperative margin assessment is becoming feasible. SIGNIFICANCE By establishing the relatively short history of mass spectrometry techniques applied to surgical studies, we hope to inform future applications and aid in the selection of suitable data analysis frameworks for the development of intraoperative margin detection technologies.
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Mansilla-Polo M, Ruiz-Merino G, Marín-Rodríguez P, Iborra-Lacal E, Guzmán-Aroca F, M Servet Pérez de Lema C, Marín-Hernández C, Polo-García L, Piñero-Madrona A. Cavity shaving for invasive breast cancer conservative surgery: Reduced specimen volume and margin positive rates. Surg Oncol 2021; 38:101632. [PMID: 34274752 DOI: 10.1016/j.suronc.2021.101632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 07/01/2021] [Accepted: 07/11/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The cavity shaving (CS) technique was described in breast conserving surgery to reduce the rate of reoperation avoiding the need for intraoperative margin analysis. This study assesses differences in the rates of involvement of the surgical margin (requiring further surgery) and volume of surgical specimens, depending on the use or not of this technique. MATERIAL AND METHODS A retrospective cohort study was conducted in patients with breast carcinoma who underwent breast conserving surgery between 2013 and 2019. They were divided into two groups depending on whether the cavity shaving technique was used or not. Primary outcomes of the study included presence of final margin involvement, requiring need for further surgery, and the volume of excised tissue comparing the study groups. RESULTS A total of 202 cases were included: 92 in the control group and 110 in the cavity shaving group. Significant differences were found regarding involvement of the final margin (19.57% control group vs. 4.55% cavity shaving group; p = 0.010). The volume of additional surgical specimens were significantly greater in the traditional technique group than in the shaving technique (46.43 vs 13.32 cm3; p = 0.01) as was total specimen volume (143.40 vs 100.63 cm3; p = 0.022). CONCLUSIONS CS can reduce the positive margin and re-excision rates without larger-volume resections and should therefore be considered a routine technique in BCS for early-stage breast cancer.
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Affiliation(s)
- Miguel Mansilla-Polo
- Surgery Department. Hospital Clínico Universitario "Virgen de La Arrixaca". Murcia. Spain. Instituto Murciano de Investigación Biosanitaria (IMIB), Spain
| | - Guadalupe Ruiz-Merino
- Biostatistics Department. Fundación para la Formación e Investigación Sanitaria (FFIS), Murcia, Spain
| | - Pedro Marín-Rodríguez
- Surgery Department. Hospital Clínico Universitario "Virgen de La Arrixaca". Murcia. Spain. Instituto Murciano de Investigación Biosanitaria (IMIB), Spain
| | - Emma Iborra-Lacal
- Pathology Department. Hospital Clínico Universitario "Virgen de La Arrixaca", Murcia, Spain
| | | | | | - Caridad Marín-Hernández
- Surgery Department. Hospital Clínico Universitario "Virgen de La Arrixaca". Murcia. Spain. Instituto Murciano de Investigación Biosanitaria (IMIB), Spain
| | - Luis Polo-García
- Pathology Department. Hospital Clínico Universitario "Virgen de La Arrixaca", Murcia, Spain
| | - Antonio Piñero-Madrona
- Surgery Department. Hospital Clínico Universitario "Virgen de La Arrixaca". Murcia. Spain. Instituto Murciano de Investigación Biosanitaria (IMIB), Spain.
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Intraoperative fluorescence imaging with aminolevulinic acid detects grossly occult breast cancer: a phase II randomized controlled trial. Breast Cancer Res 2021; 23:72. [PMID: 34253233 PMCID: PMC8276412 DOI: 10.1186/s13058-021-01442-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 05/25/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Re-excision due to positive margins following breast-conserving surgery (BCS) negatively affects patient outcomes and healthcare costs. The inability to visualize margin involvement is a significant challenge in BCS. 5-Aminolevulinic acid hydrochloride (5-ALA HCl), a non-fluorescent oral prodrug, causes intracellular accumulation of fluorescent porphyrins in cancer cells. This single-center Phase II randomized controlled trial evaluated the safety, feasibility, and diagnostic accuracy of a prototype handheld fluorescence imaging device plus 5-ALA for intraoperative visualization of invasive breast carcinomas during BCS. METHODS Fifty-four patients were enrolled and randomized to receive no 5-ALA or oral 5-ALA HCl (15 or 30 mg/kg). Forty-five patients (n = 15/group) were included in the analysis. Fluorescence imaging of the excised surgical specimen was performed, and biopsies were collected from within and outside the clinically demarcated tumor border of the gross specimen for blinded histopathology. RESULTS In the absence of 5-ALA, tissue autofluorescence imaging lacked tumor-specific fluorescent contrast. Both 5-ALA doses caused bright red tumor fluorescence, with improved visualization of tumor contrasted against normal tissue autofluorescence. In the 15 mg/kg 5-ALA group, the positive predictive value (PPV) for detecting breast cancer inside and outside the grossly demarcated tumor border was 100.0% and 55.6%, respectively. In the 30 mg/kg 5-ALA group, the PPV was 100.0% and 50.0% inside and outside the demarcated tumor border, respectively. No adverse events were observed, and clinical feasibility of this imaging device-5-ALA combination approach was confirmed. CONCLUSIONS This is the first known clinical report of visualization of 5-ALA-induced fluorescence in invasive breast carcinoma using a real-time handheld intraoperative fluorescence imaging device. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01837225 . Registered 23 April 2013.
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Cartagena LC, McGuire K, Zot P, Pillappa R, Idowu M, Robila V. Breast-Conserving Surgeries With and Without Cavity Shave Margins Have Different Re-excision Rates and Associated Overall Cost: Institutional and Patient-Driven Decisions for Its Utilization. Clin Breast Cancer 2021; 21:e594-e601. [PMID: 33814286 DOI: 10.1016/j.clbc.2021.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Reducing the rate of margin positivity and reoperations remains a paramount goal in breast-conserving surgery (BCS). This study assesses the effectiveness of standard partial mastectomy with cavity shave margins (CSM) compared with partial mastectomy with selective margin resection (SPM), with regard to outcomes of the initial surgeries, re-excisions, and overall costs. PATIENTS AND METHODS This is a retrospective review of 122 eligible breast cancer patients who underwent BCS at one institution. The CSM and SPM groups each included 61 patients, matched for presurgical diagnoses and clinical stage. Data including margin status, rates and reason for re-excision, associated operation times, and costs were analyzed. RESULTS Patients undergoing CSM had less than half the rate of positive margins (PMs) (10% vs. 23%; P = .03) and re-excisions (8% vs. 23%; P = .02) compared with SPM. In the former group, the margin involvement was focal, and re-excisions were performed almost exclusively for PMs. For SPM, the majority (92%) of PMs were on the main lumpectomy specimen rather than the selective margins, and re-excisions included, in addition to PMs, extensive or multifocal negative but close margins. Reduced breast tissue volumes were removed with CSM, particularly for patients undergoing a single surgery (47 vs. 165 cm3; P < .001). The initial surgery with CSM is on average 27% more costly than that for SPM (P < .001), due to the increased pathology costs which are partially offset by the increased re-excision rates in SPM. CONCLUSION Circumferential cavity shaving, associated with consistent lower PMs, tissue volumes excised, and re-excision rates, is appropriate for routine implementation as a method offering superior surgical outcomes.
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Affiliation(s)
| | - Kandace McGuire
- Department of Surgery, Virginia Commonwealth University, Richmond, VA
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Monib S, Anis K, Habashy H. Routine cavity shaves following breast conserving surgery; friend or foe? Surg Oncol 2021; 37:101521. [PMID: 33548588 DOI: 10.1016/j.suronc.2021.101521] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/30/2020] [Accepted: 01/24/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Radial margin status is considered one of the most important prognostic predictor for patients undergoing breast-conserving surgery (BCT), not only related to regional recurrence but also to 5y survival, especially in patients with invasive disease. AIM While our primary aim was to evaluate whether doing routine radial cavity shaves following at the time of primary conservative breast surgery will decrease the need for a second operation or not, our secondary aim was to assess time added to the operation to resect and mark the radial shaves, as well as patients' satisfaction with the results. MATERIAL AND METHODS We have conducted a case series prospective analysis, including158 patients who underwent breast-conserving surgery looking into the histological status of resection margins and radial shaves, added time taken to take and mark the shaves as well as patients' satisfaction. RESULTS 158 female breast cancer patients have been included in our analysis, the mean age was 56 years; total number of lesions was 160. While 89.3% of lesions were palpable, 10.6% were not requiring wire-guided localisation. Mean tumour size was 24 mm SD 7, final histology revealed that 86.8% lesion was invasive ductal carcinoma, 5.6% invasive lobular carcinoma, 1.2% medullary carcinoma. 12.4% had invasive disease as well as DCIS, and 1.8% had DCIS only with no invasive disease. Mean preoperative breast volume was 723 ml, Mean wide local excision specimen weight was 73 g, and mean shave weight was 1.6 g. Total number of radial margins was 640, 81.8% was clear, 14.6% was close, and 3.4% was involved. Total number of shaves was 640 out of which 98.7% was clear 0.7% was close and 0.4% was involved. Out of the 160 lesions, 3.7% required a second procedure to clear margins, out of which 2.5% had re-excision for close or involved single shaves each while 1.2% had mastectomy due to close or involved two shaves each. Average time utilised in resection of radial shaves and marking was 7 min 0.6% of patients developed a haematoma, 1.8% had a Seroma, and 1.2% had wound infection. Mean hospital stay was 1day SD 1. CONCLUSION Routine radial cavity shaves not only ensure microscopic clearance, reduce the need for re-excision with no significant added operating time but also has no impact on patients' satisfaction.
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Affiliation(s)
- Sherif Monib
- St Albans Hospital Breast Unit, West Hertfordshire Hospitals NHS Trust, UK.
| | - Karim Anis
- St Albans Hospital Breast Unit, West Hertfordshire Hospitals NHS Trust, UK
| | - Hany Habashy
- General Surgery Department, Fayoum University Hospital, Fayoum, Egypt
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Mohamedahmed AYY, Zaman S, Srinivasan A, Peterknecht E, Saeed S Mohammed S, AlBendary M, Alnzaer AA, Elsamani K. Do we need to routinely perform cavity shaving with breast-conserving surgery for breast cancer? A systematic review and meta-analysis. Surg Oncol 2020; 36:7-14. [PMID: 33271465 DOI: 10.1016/j.suronc.2020.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/30/2020] [Accepted: 11/15/2020] [Indexed: 11/29/2022]
Abstract
AIMS To evaluate comparative outcomes of breast-conserving surgery (BCS) of breast cancer with and without cavity shaving. METHODS A systematic search of multiple electronic data sources was conducted, and all randomised controlled trials (RCTs) comparing BCS with or without cavity shaving for breast cancer were included. Positive margin rate, second operation rate, operative time, post-operative haematoma, cosmetic appearance and budget cost were the evaluated outcome parameters for the meta-analysis. RESULTS Six RCTs reporting a total number of 971 patients; 495 of these underwent BCS plus shaving (BCS + S), and 473 underwent BCS alone were included. BCS + S showed significantly lower positive margin rate (Risk Ratio [RR] 0.40, P = 0.00001) and second operation rate (RR 0.38, P = 0.00001). BCS + S demonstrated longer operative time than BCS (79 ± 4 min vs 67 ± 3 min, Mean Difference 12.14, P = 0.002), and there was no significant difference in the risk of post-operative haematoma (RR 0.33, P = 0.20). CONCLUSION BCS + S is superior to BCS in terms of positive margins rate and second operation rate. Operative time is longer when cavity shaving is performed.
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Affiliation(s)
- Ali Yasen Y Mohamedahmed
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.
| | - Shafquat Zaman
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Ananth Srinivasan
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Elizabeth Peterknecht
- Department of General Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Mohamed AlBendary
- Department of Anaesthesia, Sudan Medical Specialisation Board, Khartoum, Sudan
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Silva E, Tan M. The Impact of Margin Status on Breast Conservation Rates. Ann Surg Oncol 2019; 26:3931-3938. [PMID: 31482391 DOI: 10.1245/s10434-019-07641-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Contemporary data indicate that breast conservation treatment (BCT) results in superior survival outcomes compared with mastectomy. However, positive margins after lumpectomy have implications for local control, and re-excisions are recommended to achieve negative margins. The need for reoperations after an initial attempt at BCT is associated with higher chance of conversion to mastectomy. Achieving negative margins at the first therapeutic surgical procedure is therefore critical to optimise BCT rates and survival outcomes. METHODS A compilation of scientific reports on BCT, margin status, rates of reoperation, and the impact on BCT rates was reviewed. Re-excision rates after initial lumpectomy is variable to a staggering degree and reported to be between 0 and 100%. High reoperation rates (ROR) are associated with higher likelihood of conversion to mastectomy, which may not confer favourable treatment outcomes. Although widely agreed that decreasing ROR is a desirable objective, there is controversy regarding the need for its urgent implementation as a quality metric. Critics of this cite challenges related to how this can be achieved and its attendant ramifications. On the other hand, without the appropriate incentive for quality improvement of surgical treatment of breast cancer, patients may be subject to poorer overall outcomes. DISCUSSION Techniques and approaches are discussed in this article to enable a reduction in positive margin status, and therefore ROR. The rationale for achieving ROR of 10-20% are explicated, as well as the impact this would have on BCT rates, which translates to better survival outcomes for women with breast cancer.
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Affiliation(s)
- Edibaldo Silva
- Surgical Oncology, University of Nebraska Medical Center, Omaha, USA.
| | - Mona Tan
- MammoCare, Breast Surgery, Singapore, Singapore
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Park KU, Kuerer HM, Rauch GM, Leung JWT, Sahin AA, Wei W, Li Y, Black DM. Digital Breast Tomosynthesis for Intraoperative Margin Assessment during Breast-Conserving Surgery. Ann Surg Oncol 2019; 26:1720-1728. [DOI: 10.1245/s10434-019-07226-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Indexed: 11/18/2022]
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McEvoy MP, Landercasper J, Naik HR, Feldman S. Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic. Gland Surg 2018; 7:536-553. [PMID: 30687627 DOI: 10.21037/gs.2018.11.03] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2015, the American Society of Breast Surgeons (ASBrS) convened a multidisciplinary consensus conference, the Collaborative Attempt to Lower Lumpectomy Reoperation Rates (CALLER). The CALLER conference endorsed a "toolbox" of multiple processes of care for which there was evidence that they were associated with fewer reoperations. We present an update of the toolbox taking into consideration the latest advances in decreasing re excision rates. In this review, we performed a comprehensive review of the literature from 2015-2018 using search terms for each tool. The original ten tools were updated with the latest evidence from the literature and our strength of recommendation. We added an additional section looking at new tools and techniques that may provide more accurate intraoperative assessment of margins. The updates on the CALLER Toolbox for lumpectomy will help guide surgeons to various resources to aid in the removal of breast cancer, while being aware of cosmesis and decreasing re excision rates.
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Affiliation(s)
- Maureen P McEvoy
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
| | - Jeffrey Landercasper
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Himani R Naik
- Gundersen Health System, Norma J. Vinger Center for Breast Cancer, La Crosse, WI, USA
| | - Sheldon Feldman
- Montefiore Medical Center, Montefiore Einstein Center for Cancer Care, Bronx, NY, USA
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Clement Z, McLeay W, Hoffmann C, Shin P, Chowdhry M, Eaton M. Re-excision rate after sector resection for breast cancer: A 5-year retrospective cohort study. Breast Dis 2018; 38:7-13. [PMID: 30198861 DOI: 10.3233/bd-180339] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Positive margins after Breast conserving surgery (BCS) for breast cancer can result in local recurrence (LR) requiring further surgery. This can lead to unnecessary patient anxiety, poor prognosis and impose additional economic burden to our health system. The aim of this study is to assess the rate of re-excision for positive margins after BCS using the sector resection technique. METHODS This single centre retrospective cohort study included all women who underwent BCS using sector resection between the years of 2012 and 2016. A total of 456 patients underwent sector resection. We evaluated the margin status, re-excision rates and their predictive risk factors. RESULTS 415 (91%) patients had clear margins. 41 (9%) patients underwent further re-excision for positive or close margin. 75.6% of those patients had DCIS and 51% had invasive carcinoma involving the margins. Patient and tumour characteristics associated with an increased risk of positive margin were women under the age of 50 (p = 0.19), tumours >50 mm (p = 0.001), grade-2 (p = 0.48) and grade-3 (p = 0.63), HER-2 positivity (p = 0.02), sentinel lymph node positivity (p = 0.03), and patients undergoing axillary lymph node dissection (p = 0.01). CONCLUSION BCS using the sector resection technique has a low re-excision rate for positive margins. Younger patients and aggressive tumour biology are important predictive risk factors for positive margins.
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Affiliation(s)
- Zackariah Clement
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - William McLeay
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Clive Hoffmann
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Peter Shin
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Munir Chowdhry
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia
| | - Michael Eaton
- Breast and Endocrine Surgery Unit, Flinders Medical Centre, Adelaide, Australia.,Medical School, Flinders University, Adelaide, Australia
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13
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Chagpar AB, Wilke LG. Should Reexcision Rates in Breast Cancer Care be a Quality Measure? Ann Surg Oncol 2018; 25:2818-2822. [PMID: 29947002 DOI: 10.1245/s10434-018-6576-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, 20 York Street, First Floor, Suite A, New Haven, CT, USA.
| | - Lee G Wilke
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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14
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Larson KE, Jadeja P, Marko A, Jadeja V, Pratt D. Radiographically guided shave margins may reduce lumpectomy re-excision rates. Breast J 2018; 24:820-822. [DOI: 10.1111/tbj.13050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Kelsey E. Larson
- Department of Breast Surgery; Cleveland Clinic; Cleveland OH USA
| | | | - Alison Marko
- Northeast Ohio Medical University; Rootstown OH USA
| | | | - Debra Pratt
- Cleveland Clinic; Fairview Hospital; Cleveland OH USA
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15
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Corsi F, Sorrentino L, Bonzini M, Bossi D, Truffi M, Amadori R, Nebuloni M, Brillat B, Mazzucchelli S. Cavity Shaving Reduces Involved Margins and Reinterventions Without Increasing Costs in Breast-Conserving Surgery: A Propensity Score-Matched Study. Ann Surg Oncol 2017; 24:1516-1524. [DOI: 10.1245/s10434-017-5774-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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16
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Scientific surgery. Br J Surg 2017. [DOI: 10.1002/bjs.10539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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