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Background Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates. Methods Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected. Results Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent). Conclusion Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.

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Objective: Failure to achieve adequate margins after breast-conserving surgery often leads to re-excision, either by repeat breast-conserving surgery (BCS) or by mastectomy. Despite the high frequency of this problem, the success rate of achieving adequate margins by repeat BCS is not well documented. The objective of this study was to determine the success rate of repeat BCS and identify the factors influencing that rate. Materials and Methods:A retrospective review was performed of all women undergoing repeat BCS for inadequate margins after initial BCS in our breast unit between 2013 and 2019. Univariate and multivariate analyses were carried out to identify the factors influencing how often adequate margins were achieved after repeat BCS.Results: One hundred fifty-four patients underwent repeat BCS after initially inadequate margins, of which adequate margins were achieved in 82%. Patients with successful repeat BCS had smaller tumors, had less underestimation of tumor size on imaging, and were less likely to have had cavity shaves taken at their initial BCS. A tumor size more than 50% larger than predicted by imaging was independently associated with failure of repeat BCS in multivariate analysis (odds ratio: 3.6, 95% CI: 1.41-9.20, p = 0.007). Underestimation of tumor size by imaging was commoner and more extensive in patients with larger tumors and those with ductal carcinoma in situ. Conclusion:Re-excision by cavity shaves has a high success rate and should be offered to all patients who are deemed suitable for the procedure. Patients whose tumors are more than 50% larger than predicted by imaging should be counseled about the higher risk of failure.

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