Margin re‐excision and local recurrence in invasive breast cancer: A cost analysis using a decision tree model

Abe, Shoko; Hill, Joshua S.; Han, Yimei; Walsh, Kendall; Symanowski, James T.; Hadžikadić-Gušić, Lejla; Flippo‐Morton, Teresa S.; Sarantou, Terry; Forster, M.C.; White, Richard L.

doi:10.1002/jso.23990

Cited by 49 publications

(49 citation statements)

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“…Interestingly, only relatively small further reductions in re-operation rates from 20.2% to 16.5% [52] and from 21.4% to 15.1% [53] have been observed following acceptance of the 2014 SSO-ASTRO guidelines and these reduced rates could still be considered excessive. Extrapolation of re-operative rates of 15% combined with the annual incidence of breast cancer and the increasing popularity of breast conserving surgery, amounts to many thousands of women undergoing potentially unnecessary operations with a significant health and economic cost to the patient and healthcare provider [13]. The fact that re-operation rates of 3.6% have been demonstrated following breast conserving surgery with the use of routine frozen section margin assessment [17] provides evidence that IMA techniques or technologies with high diagnostic accuracy could be expected to substantially reduce positive margin rates beyond those achieved by a reduction in positive margin width alone.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, re-operation increases healthcare costs. For example, an economic model of re-excision of breast margins in the USA predicted that in comparison to positive margins, re-excision of close margins (<2 mm) accounts for an additional US$18.8 million per year whilst eliminating re-excision of margins ultimately found to be negative would save a further US$16.4 million per year [13]. …”

Section: Introductionmentioning

confidence: 99%

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Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

et al. 2017

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BackgroundRe-operation for positive resection margins following breast-conserving surgery occurs frequently (average = 20–25%), is cost-inefficient, and leads to physical and psychological morbidity. Current margin assessment techniques are slow and labour intensive. Rapid evaporative ionisation mass spectrometry (REIMS) rapidly identifies dissected tissues by determination of tissue structural lipid profiles through on-line chemical analysis of electrosurgical aerosol toward real-time margin assessment.MethodsElectrosurgical aerosol produced from ex-vivo and in-vivo breast samples was aspirated into a mass spectrometer (MS) using a monopolar hand-piece. Tissue identification results obtained by multivariate statistical analysis of MS data were validated by histopathology. Ex-vivo classification models were constructed from a mass spectral database of normal and tumour breast samples. Univariate and tandem MS analysis of significant peaks was conducted to identify biochemical differences between normal and cancerous tissues. An ex-vivo classification model was used in combination with bespoke recognition software, as an intelligent knife (iKnife), to predict the diagnosis for an ex-vivo validation set. Intraoperative REIMS data were acquired during breast surgery and time-synchronized to operative videos.ResultsA classification model using histologically validated spectral data acquired from 932 sampling points in normal tissue and 226 in tumour tissue provided 93.4% sensitivity and 94.9% specificity. Tandem MS identified 63 phospholipids and 6 triglyceride species responsible for 24 spectral differences between tissue types. iKnife recognition accuracy with 260 newly acquired fresh and frozen breast tissue specimens (normal n = 161, tumour n = 99) provided sensitivity of 90.9% and specificity of 98.8%. The ex-vivo and intra-operative method produced visually comparable high intensity spectra. iKnife interpretation of intra-operative electrosurgical vapours, including data acquisition and analysis was possible within a mean of 1.80 seconds (SD ±0.40).ConclusionsThe REIMS method has been optimised for real-time iKnife analysis of heterogeneous breast tissues based on subtle changes in lipid metabolism, and the results suggest spectral analysis is both accurate and rapid. Proof-of-concept data demonstrate the iKnife method is capable of online intraoperative data collection and analysis. Further validation studies are required to determine the accuracy of intra-operative REIMS for oncological margin assessment.Electronic supplementary materialThe online version of this article (doi:10.1186/s13058-017-0845-2) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

et al. 2017

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“…WLE often fails to achieve clear surgical margins, and on average 20% of patients who undergo BCS will require repeated surgery to achieve clear margins (1) (although this may vary because there is no global agreement of the definition of clear margins). Reoperations potentially have several negative consequences including delayed commencement of adjuvant therapy, worse cosmesis, increased patient anxiety, and costs (2,3).…”

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confidence: 99%

Intraoperative Assessment of Tumor Resection Margins in Breast-Conserving Surgery Using ¹⁸F-FDG Cerenkov Luminescence Imaging: A First-in-Human Feasibility Study

et al. 2016

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In early-stage breast cancer, the primary treatment option for most women is breast-conserving surgery (BCS). There is a clear need for more accurate techniques to assess resection margins intraoperatively, because on average 20% of patients require further surgery to achieve clear margins. Cerenkov luminescence imaging (CLI) combines optical and molecular imaging by detecting light emitted by 18 F-FDG. Its high-resolution and small size imaging equipment make CLI a promising technology for intraoperative margin assessment. A first-in-human study was conducted to evaluate the feasibility of 18 F-FDG CLI for intraoperative assessment of tumor margins in BCS. Methods: Twenty-two patients with invasive breast cancer received 18 F-FDG (5 MBq/kg) 45-60 min before surgery. Sentinel lymph node biopsy was performed using an increased 99m Tc-nanocolloid activity of 150 MBq to facilitate nodal detection against the g-probe background signal (cross-talk) from 18 F-FDG. The cross-talk and 99m Tc dose required was evaluated in 2 lead-in studies. Immediately after excision, specimens were imaged intraoperatively in an investigational CLI system. The first 10 patients were used to optimize the imaging protocol; the remaining 12 patients were included in the analysis dataset. Cerenkov luminescence images from incised BCS specimens were analyzed postoperatively by 2 surgeons blinded to the histopathology results, and mean radiance and margin distance were measured. The agreement between margin distance on CLI and histopathology was assessed. Radiation doses to staff were measured. Results: Ten of the 12 patients had an elevated tumor radiance on CLI. Mean radiance and tumor-to-background ratio were 560 6 160 photons/s/cm 2 /sr and 2.41 6 0.54, respectively. All 15 assessable margins were clear on CLI and histopathology. The agreement in margin distance and interrater agreement was good (k 5 0.81 and 0.912, respectively). Sentinel lymph nodes were successfully detected in all patients. The radiation dose to staff was low; surgeons received a mean dose of 34 6 15 mSv per procedure. Conclusion: Intraoperative 18 F-FDG CLI is a promising, low-risk technique for intraoperative assessment of tumor margins in BCS. A randomized controlled trial will evaluate the impact of this technique on reexcision rates. In early-stage breast cancer, the primary treatment option for most women is breast-conserving surgery (BCS) by wide local excision (WLE) of the tumor. WLE often fails to achieve clear surgical margins, and on average 20% of patients who undergo BCS will require repeated surgery to achieve clear margins (1) (although this may vary because there is no global agreement of the definition of clear margins). Reoperations potentially have several negative consequences including delayed commencement of adjuvant therapy, worse cosmesis, increased patient anxiety, and costs (2,3).There have been several attempts to assess surgical margins intraoperatively to reduce breast cancer reoperation rates after WLE (1). Techniques evaluated to date in...

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“…Surgical costs estimated using Medicare reimbursement rates would decrease more than $20 million dollars if no re-excisions were performed for close or negative margins. 30 Beyond resource utilization and physician effort, it is also important to consider the opportunity cost, missed work days for patients and caregivers, and the non-negligible distress caused by the need to return for surgery and the delay to adjuvant therapy. In our study, 81 hours of operating room time were committed to re-excisions which would not have occurred under the consensus guideline, and this represents potential consequences on a wider scale to other patients who may have received their surgical procedures during this time.…”

Section: Discussionmentioning

confidence: 99%

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

Elmore

Cyr

et al. 2017

Journal of the American College of Surgeons

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Background The SSO/ASTRO consensus statement was the first professional guideline in breast oncology to declare “no ink on tumor” as a negative margin in patients with stages I/II breast cancer undergoing breast conservation therapy (BCT). We sought to analyze the financial impact of this guideline at our institution using a historic cohort. Study Design We identified women undergoing re-excision following breast-conserving surgery for invasive breast cancer from 2010–2013 using a prospectively-maintained institutional database. Clinical and billing data were extracted from the medical record and from administrative resources using CPT codes. Descriptive statistics were used in data analysis. Results Of 254 women in the study population, 238 (93.7%) had stage I/II disease and 182 (71.7%) had invasive disease with DCIS. A subcohort of 83 patients (32.7%) who underwent BCT for Stage I/II disease without neoadjuvant chemotherapy had negative margins after the index procedure per the SSO/ASTRO guideline. The majority had invasive ductal carcinoma (70, 84.3%) and had invasive disease (45, 54.2%) and/or DCIS (49, 59.0%) within 1 mm of the specimen margin. Seventy-nine patients underwent one re-excision, and 4 patients underwent two re-excisions, accounting for 81 hours of operative time. Considering facility fees and primary surgeon billing alone, the overall estimated cost reduction would have been $195,919, or $2,360 per affected patient, under the guideline recommendations. Conclusions Implementation of the SSO/ASTRO consensus guideline holds great potential to optimize resource utilization. Application of the guideline to a retrospective cohort at our institution would have decreased the overall re-excision rate by 5.6% and reduced costs by nearly $200,000. Further analysis of patient outcomes and margin assessment methods is needed to define the long-term impact on surgical practice.

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Margin re‐excision and local recurrence in invasive breast cancer: A cost analysis using a decision tree model

Abstract: The strategy of re-excising close margins resulted in a predicted cost of $18.8 million per year. This does not include hospital costs, the cost of surgical complications after re-excision, and underestimates the potential savings by using Medicare reimbursement rates.

Cited by 49 publications

References 41 publications

Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

Intraoperative Assessment of Tumor Resection Margins in Breast-Conserving Surgery Using ¹⁸F-FDG Cerenkov Luminescence Imaging: A First-in-Human Feasibility Study

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

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Margin re‐excision and local recurrence in invasive breast cancer: A cost analysis using a decision tree model

Abstract: The strategy of re-excising close margins resulted in a predicted cost of $18.8 million per year. This does not include hospital costs, the cost of surgical complications after re-excision, and underestimates the potential savings by using Medicare reimbursement rates.

Cited by 49 publications

References 41 publications

Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

Rapid evaporative ionisation mass spectrometry of electrosurgical vapours for the identification of breast pathology: towards an intelligent knife for breast cancer surgery

Intraoperative Assessment of Tumor Resection Margins in Breast-Conserving Surgery Using 18F-FDG Cerenkov Luminescence Imaging: A First-in-Human Feasibility Study

Cost Analysis of a Surgical Consensus Guideline in Breast-Conserving Surgery

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Intraoperative Assessment of Tumor Resection Margins in Breast-Conserving Surgery Using ¹⁸F-FDG Cerenkov Luminescence Imaging: A First-in-Human Feasibility Study