Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference

Abstract

BackgroundMultiple recent reports have documented significant variability of reoperation rates after initial lumpectomy for breast cancer. To address this issue, a multidisciplinary consensus conference was convened during the American Society of Breast Surgeons 2015 annual meeting.MethodsThe conference mission statement was to “reduce the national reoperation rate in patients undergoing breast conserving surgery for cancer, without increasing mastectomy rates or adversely affecting cosmetic outcome, thereby improving value of care.” The goal was to develop a toolbox of recommendations to reduce the variability of reoperation rates and improve cosmetic outcomes. Conference participants included providers from multiple disciplines involved with breast cancer care, as well as a patient representative. Updated systematic reviews of the literature and invited presentations were sent to participants in advance. After topic presentations, voting occurred for choice of tools, level of evidence, and strength of recommendation.ResultsThe following tools were recommended with varied levels of evidence and strength of recommendation: compliance with the SSO-ASTRO Margin Guideline; needle biopsy for diagnosis before surgical excision of breast cancer; full-field digital diagnostic mammography with ultrasound as needed; use of oncoplastic techniques; image-guided lesion localization; specimen imaging for nonpalpable cancers; use of specialized techniques for intraoperative management, including excisional cavity shave biopsies and intraoperative pathology assessment; formal pre- and postoperative planning strategies; and patient-reported outcome measurement.ConclusionsA practical approach to performance improvement was used by the American Society of Breast Surgeons to create a toolbox of options to reduce lumpectomy reoperations and improve cosmetic outcomes.

Reoperation Costs in Attempted Breast-Conserving Surgery: A Decision Analysis

“…Recent efforts to standardize the approach to addressing pathologic margin status also have the potential to effect reoperation rates 45 . Although no clear single solution has emerged, high variability suggests this intervention could be a useful quality measure 7,11,12 , or at least a factor that affects patient satisfaction and cost 46,47 .…”

“…Although no consensus on the optimal reoperation rate has been reached, several international bodies have, as noted earlier, suggested that reducing the number of repeat operations is a necessity [7][8][9] , with one organization suggesting 10% as a goal 9 . A number of institutional publications have reported reoperation rates close to that benchmark 1,8,34 , suggesting that it is achievable.…”

“…Although no rate has achieved universal acceptance, many experts have suggested that the 23% rate is too high 7,8 , and the European Society of Breast Cancer Specialists has suggested that 10% be the goal 9 .…”

“…The potential consequences of reoperation include social and psychological stressors, increased morbidity, and inferior cosmetic outcome 10 . Others have suggested that the frequency of reoperation after attempted bcs be considered for use as a quality measure in breast cancer surgery 7,11,12 , in part because of the aforementioned concerns. In addition, further surgery likely has significant associated economic costs, although the magnitude of those costs is poorly understood 12 .…”

Dielectric-technique-assisted breast cancer surgery

“…The success of local treatment depends on having clear resection margins. Residual cancer in resection margins can be found in as many as 20-46% of patients treated by BCT [2][3][4] which significantly increases the risk of recurrence, with ductal carcinoma in situ (DCIS) being particularly difficult to excise [5]. It is therefore vital to evaluate the clearance of excision margins.…”