Fewer Reoperations After Lumpectomy for Breast Cancer with Neoadjuvant Rather than Adjuvant Chemotherapy: A Report from the National Cancer Database

The Effect of Intraoperative Margin Assessment During Breast Conserving Surgery for Breast Cancer in a Dutch Cohort

INTRODUCTION

Intraoperative specimen radiography is a routinely used procedure to ensure adequate resection of non-palpable breast tumors. Intraoperative digital specimen mammography (IDSM) is an alternative to conventional specimen radiography (CSR) which provides immediate specimen evaluation and can potentially decrease operation time. IDSM may also result in lower positive margin and re-excision rates. IDSM was implemented in our hospital in 2018. The objective of this study was to evaluate the effect of using IDSM versus CSR on operation time, margin status and re-excision rates in breast conserving surgery.

METHODS

The present study is a single-center retrospective cohort study with 2 patient cohorts: one which underwent CSR (n = 532) and one which underwent IDSM (n = 475). The primary outcome was the operation time. Secondary outcomes were the margin status of the primary surgery, the cavity shaving rate, and the re-excision rate. Differences between cohorts were compared using univariate statistics and multiple regression analyses to adjust for variables that were significantly different between the groups.

RESULTS

IDSM use was associated with an 8-minute reduction in surgery time (B = -8.034, 95% CI [-11.6, -4.5]; P < .001). Treatment variables independently associated with the operation time included use of IDSM, type of surgery, and performance of cavity shaving. Cavity shaves were more often performed when IDSM was used (24% for IDSM vs. 14% for CSR, P < .001), while the proportion of negative margin rates (93% for IDSM vs. 96% for CSR, P = .070) was comparable.

CONCLUSION

IDSM was associated with a modest reduction in operation time. Surgeons performed more cavity shaves since the introduction of IDSM, but this increase was not reflected by difference in negative margin rates.

Patterns of care over 10 years in young breast cancer patients in the Netherlands, a nationwide population-based study

INTRODUCTION

Each year, around 600 young (<40 years) breast cancer (BC) patients are registered in the national NABON Breast Cancer Audit (NBCA). The aim of this study is to compare patient and treatment characteristics of young and older age BC patients over time with a focus on outcome of quality indicators (QIs). Furthermore, we analysed whether de-escalation trends of treatment can be recognized to the same degree in both patient groups.

MATERIAL AND METHODS

From October 2011 to October 2020 all patients treated for stage I-III invasive BC were included. Tumour characteristics, treatment variables and outcome of QIs of two age categories young (<40 years) and older patient (≥40 years) were analysed.

RESULTS

In total 114,700 patients were included: 4.6% young patients and 95.4% older patients. Young patients more often presented with a palpable mass, higher stage, and triple-negative BC. Overall, young patients more often started with neoadjuvant systemic treatment (NST) (54.3% vs. 18.6%) and a greater proportion of the young patients retained their breast contour after surgery (73.5% vs. 69.3%). De-escalation trends such as decrease in axillary lymph node dissections and in the use of boost were observed. The omission of radiation treatment after breast conserving surgery was only observed in older patients.

CONCLUSION

Although this study shows that young women more often present with unfavourable tumours, therapeutic procedures are performed with a higher adherence to the QIs than for older patients and young women do benefit from some de-escalation trends to the same extend as older patients.

Innovative Standards in Surgery of the Breast after Neoadjuvant Systemic Therapy

BACKGROUND

The goal of neoadjuvant systemic therapy (NST) in breast cancer is to downstage tumors and downgrade treatment. Indications are constantly evolving. These changes raise practical questions for planning of surgery after NST.

SUMMARY

In this review we discuss current evolving aspects of surgery of the breast after NST. Breast-conserving surgery (BCS) eligibility increases after NST - both neoadjuvant chemotherapy (NAC) and neoadjuvant endocrine therapy. Adequate margin width in NST and upfront surgery are similar - "no tumor on ink" for invasive cancer. Oncoplastic breast surgery after NST is feasible - both for BCS and mastectomy with reconstruction. There is increasing interest in the possibility of omitting surgery in patients with a complete response to NAC. Several trials are being conducted in aim of achieving acceptable prediction of pathological complete response, by combination of imaging and percutaneous biopsy of the tumor bed, as well as assessing the safety of such an approach.

KEY MESSAGES

Surgery of the breast after NST should be determined not only according to biologic and anatomic parameters at diagnosis, but is dynamic, and must be tailored according to the response to therapy. The omission of surgery in exceptional responders after NAC is being explored.

The Impact of Neoadjuvant Chemotherapy on Margin Re-excision in Breast-Conserving Surgery

BACKGROUND

Neoadjuvant chemotherapy (NAC) can improve cosmesis by reducing resection volume. Breast-conserving surgery (BCS) aims to achieve clear excision margins while optimizing cosmesis. However, the influence of NAC on margin re-excision after BCS is unclear. This study examines the rate and determinants of margin re-excision in patients undergoing BCS following NAC in our institution.

METHODS

From 2011-2015, all patients treated with NAC prior to BCS were identified from a prospectively maintained database. Mann-Whitney and Fisher's exact test tests were used to compare variables in patients who did and did not require re-excision. Patients undergoing primary surgical treatment in 2015 comprised an unmatched comparison group.

RESULTS

Of 211 patients treated with NAC, 69 initially underwent BCS. The re-excision rate was 32% (n = 22) compared to 17% in the primary operable group (38 of 221, p = 0.02). Re-excision rates were lowest in triple-negative and HER2+ tumors (0% and 10%, respectively). Lobular carcinoma and ER+ tumors had a significantly higher rate of re-excision (100% and 42%, respectively). Of 22 patients undergoing re-excision, 9 had further BCS and 13 had a mastectomy.

CONCLUSION

The re-excision rate following NAC is almost twice that of patients who underwent primary operative management. Her2+ and triple-negative tumors have lower re-excision rates and may represent a selected cohort most suitable for BCS. Patients with invasive lobular carcinoma or ER+ disease have significantly higher rates of margin positivity, and these patients should be considered for a cavity shave during primary surgery to reduce the rates of re-excision.

Surgical Treatment after Neoadjuvant Systemic Therapy in Young Women with Breast Cancer: Results from a Prospective Cohort Study

OBJECTIVE

We aimed to investigate eligibility for breast-conserving surgery (BCS) pre- and post-neoadjuvant systemic therapy (NST), and trends in the surgical treatment of young breast cancer patients.

BACKGROUND

Young women with breast cancer are more likely to present with larger tumors and aggressive phenotypes, and may benefit from NST. Little is known about how response to NAC influences surgical decisions in young women.

METHODS

The Young Women's Breast Cancer Study (YWS), a multicenter prospective cohort of women diagnosed with breast cancer at age ≤40, enrolled 1302 patients from 2006 to 2016. Disease characteristics, surgical recommendations, and reasons for choosing mastectomy among BCS-eligible patients were obtained through the medical record. Trends in use of NST, rate of clinical and pathologic complete response (cCR and pCR), and surgery were also assessed.

RESULTS

Of 1117 women with unilateral stage I-III breast cancer, 315 (28%) received NST. Pre-NST, 26% were BCS eligible, 17% were borderline eligible, and 55% were ineligible. After NST, BCS eligibility increased from 26% to 42% (p < 0.0001). Among BCS-eligible patients after NST (n = 133), 41% chose mastectomy with reasons being patient preference (53%), BRCA or TP53 mutation (35%) and family history (5%). From 2006 to 2016, the rates of NST (p = 0.0012), cCR (p < 0.0001) and bilateral mastectomy (p < 0.0001) increased, but the rate of BCS did not increase (p = 0.34).

CONCLUSION

While the proportion of young women eligible for BCS increased after NST, many patients choose mastectomy, suggesting that surgical decisions are often driven by factors beyond extent of disease and treatment response.

Evaluating the effect of neoadjuvant chemotherapy on surgical outcomes after breast conserving surgery

BACKGROUND

Neoadjuvant chemotherapy (NAC) increases breast-conserving surgery (BCS) rates with comparable locoregional control and survival outcomes to adjuvant therapy. More women are receiving NAC and achieving pathologic complete responses (pCR). This study sought to evaluate the effect of NAC on surgical outcomes after the adoption of a "no-ink-on-tumor" margin policy in patients undergoing primary BCS (PBSC).

METHODS

An IRB approved database was queried for women undergoing BCS for invasive breast cancer after March 2014. We compared patients who underwent NAC followed by BCS versus PBCS. Demographic, tumor, treatment, and outcome variables were compared using both univariate and multivariable analysis.

RESULTS

A total of 162 patients were evaluated. NAC patients had significantly lower re-excision rates (0% NAC vs. 9% PBCS, p = .03), margin positivity (0% NAC vs. 5% PBCS, p = .01), and greater patient satisfaction with breast cosmesis (97 NAC vs. 77 PBCS, p = .01). On multivariable analysis, NAC was not an independent predictor of lower final resection volume, total complications, or greater satisfaction with breasts when controlling for age and T category at diagnosis.

CONCLUSION

NAC followed by BCS may offer less margin positivity, lower re-excision rates, and greater patient satisfaction when compared to a contemporary PBCS cohort in the "no-ink-on-tumor" era.

The Value of Repeated Breast Surgery as a Quality Indicator in Breast Cancer Care

Breast-conserving surgery, a major achievement in surgical oncology, has allowed an increasing number of breast cancer patients to avoid the mutilation of mastectomy. However, mastectomy still is performed in certain circumstances although breast-conserving surgery would be equally safe. Many reasons, including patients' and surgeons' personal motivations, influence the decision-making process before the final choice between breast preservation and mastectomy. The importance of quality measurement and reporting in medicine is increasingly recognized, and breast surgery is no exception. The substantial variability of re-excision rates for positive surgical margins after a first attempt at breast-conserving surgery suggests that improvement is possible. Therefore, the re-excision rate has been proposed as a quality metric for assessing and comparing the performance of different institutions. Indeed, re-excision rates can be reduced by actionable factors such as accurate preoperative local staging, localization of occult lesions, and intraoperative assessment of the oriented specimen. However, equally important non-actionable risk factors pertaining the biology, detectability, and resectability of the tumor also should be taken into account. Therefore, if the re-excision rate has to be used as a performance indicator of breast surgical care, critical interpretation of results with accurate case-mix adjustment are mandatory, and reasonable targets must be appropriately set so that surgeons treating patients at higher risk of positive margins are not unduly penalized.

Evaluation of 2014 margin guidelines on re-excision and recurrence rates after breast conserving surgery: A multi-institution retrospective study

Introduction

A 2014 consensus statement from the Society of Surgical Oncology and American Society for Radiation Oncology supported “no ink on tumor” as an adequate margin for breast conserving therapy (BCT). This study evaluates this statement in a multi-institution cohort.

Methods

A retrospective review of BCT cases at 3 comprehensive cancer centers was performed. Women age >18 receiving BCT for T1-2 breast cancer from 2008-2012 were included. Pre-2014, all sites considered 2 mm adequate. Estimated re-excision rates using the 2014 guidelines were calculated and factors predictive of re-excision were analyzed.

Results

542 patients (545 lumpectomies) were eligible. Using a ≥2 mm margin standard, 32.8% of patients underwent re-excision compared to 14.1% after 2014 (p < 0.0001). Tumor size (p= 0.003), grade (p=0.015), and lymphovascular invasion (p=0.021) were predictive of re-excision. Patients with additional intraoperative margins excised were less likely to require reoperation (p=0.002). Local recurrence was unaffected by re-excision after mean followup of 66 months.

Conclusions

The 2014 margin guidelines markedly reduce re-excision rates. There is no difference in local recurrence for patients after re-excision for a close margin versus without Powered.

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Multi-institution review 2014 consensus statement on margins for invasive breast cancer.

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Pooled results demonstrated a 32.8% re-excision rate reduced to 14.1% if the "no tumor on ink" guidelines were applied.

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No difference in local recurrence rates, including patients with close margins, after median followup of 67 months.

The Impact of Margin Status on Breast Conservation Rates

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.

Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members

Background

More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations.

Methods

A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery^® registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses.

Results

Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0–32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, ≥ 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline.

Conclusions

Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.

Highlights of the 16th St Gallen International Breast Cancer Conference, Vienna, Austria, 20-23 March 2019: personalised treatments for patients with early breast cancer

The 16th St Gallen International Breast Cancer Conference took place in Vienna for the third time, from 20–23 March 2019. More than 3000 people from all over the world were invited to take part in this important bi-annual critical review of the ‘state of the art’ in the primary care of breast cancer (BC), independent of political and industrial pressure, with the aim to integrate the most recent research data and most important developments in BC therapies since St Gallen International Breast Cancer Conference 2017, with the ultimate goal of drawing up a consensus for the current optimal treatment and prevention of BC.

This year, the St Gallen Breast Cancer Award was won by Monica Morrow (Memorial Sloan Kettering Cancer Center, USA) for her extraordinary contribution in research and practise development in the treatment of BC. She opened the session with the lecture ‘Will surgery be a part of BC treatment in the future?’ Improved systemic therapy has decreased BC mortality and increased pathologic complete response (pCR) rates after neoadjuvant chemotherapy (NACT). Improved imaging and increased screening uptake have led to detect smaller cancers. These factors have highlighted two possible scenarios to omit surgery: for patients with small low-grade ductal carcinoma in situ (DCIS) and for those who have received NACT and had a clinical and radiological complete response. However, considering that 7%–20% of `low-risk’ DCIS patients have co-existing invasive cancer at diagnosis, that surgery has become progressively less morbid and less toxic than some systemic therapies with a lower cost-effectiveness ratio, and that identification of pathologic complete response (pCR) without surgery requires more intensive imaging follow-up (more biopsies, higher cost and more anxiety for the patient), surgery still appears to be an essential treatment for BC.

The Umberto Veronesi Memorial Award went to Lesley Fallowfield (Brighton and Sussex Medical School, UK) for her important research and activity in the field of the development of patient outcome, of better communication skills and quality of life for women. In her lecture, she remarked on the importance of improving BC personalised treatments, especially through co-operation between scientists, always considering the whole woman and not just her breast disease. This award was given by Paolo Veronesi, after a moving introduction which culminated with the following words of Professor Umberto Veronesi:

‘It is not possible to take care of the people’s bodies without taking care of their mind. My duty, the duty of all doctors, is to listen and be part of the emotions of those we treat every day’.

Update of the American Society of Breast Surgeons Toolbox to address the lumpectomy reoperation epidemic

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.

Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch Breast Cancer Audit

INTRODUCTION

NAC has led to an increase in breast conserving surgery (BCS) worldwide. This study aims to analyse trends in the use of neoadjuvant chemotherapy (NAC) and the impact on surgical outcomes.

METHODS

We reviewed all records of cT1-4N0-3M0 breast cancer patients diagnosed between July 2011 and June 2016 who have been registered in the Dutch National Breast Cancer Audit (NBCA) (N = 57.177). The surgical outcomes of 'BCS after NAC' were compared with 'primary BCS', using a multivariable logistic regression model.

RESULTS

Between 2011 and 2016, the use of NAC increased from 9% to 18% and 'BCS after NAC' (N = 4170) increased from 43% to 57%. We observed an involved invasive margin rate (IMR) of 6,7% and a re-excision rate of 6,6%. As compared to 'primary BCS', the IMR of 'BCS after NAC' is higher for cT1 (12,3% versus 8,3%; p < 0.005), equal for cT2 (14% versus 14%; p = 0.046) and lower for cT3 breast cancer (28,3% versus 31%; p < 0.005). Prognostic factors associated with IMR for both 'primary BCS' as for 'BCS after NAC' are: lobular invasive breast cancer and a hormone receptor positive receptor status (all p < 0,005).

CONCLUSION

The use of NAC and the incidence of 'BCS after NAC' increased exponentially in time for all stages of invasive breast cancer in the Netherlands. This nationwide data confirms that 'BCS after NAC' compared to 'primary BCS' leads to equal surgical outcomes for cT2 and improved surgical outcomes for cT3 breast cancer. These promising results encourage current developments towards de-escalation of surgical treatment.