Variability in Reexcision Following Breast Conservation Surgery

Abstract

Context Health care reform calls for increasing physician accountability and transparency of outcomes. Partial mastectomy is the most commonly performed procedure for invasive breast cancer and often requires reexcision. Variability in reexcision might be reflective of the quality of care.Objective To assess hospital and surgeon-specific variation in reexcision rates following partial mastectomy. Design, Setting, and Patients An observational study of breast surgery performed between 2003 and 2008 intended to evaluate variability in breast cancer surgical care outcomes and evaluate potential quality measures of breast cancer surgery. Women with invasive breast cancer undergoing partial mastectomy from 4 institutions were studied (1 university hospital [University of Vermont] and 3 large health plans [Kaiser Permanente Colorado, Group Health, and Marshfield Clinic]). Data were obtained from electronic medical records and chart abstraction of surgical, pathology, radiology, and outpatient records, including detailed surgical margin status. Logistic regression including surgeon-level random effects was used to identify predictors of reexcision. Main Outcome Measure Incidence of reexcision.Results A total of 2206 women with 2220 invasive breast cancers underwent partial mastectomy and 509 patients (22.9%; 95% CI, 21.2%-24.7%) underwent reexcision (454 patients [89.2%; 95% CI, 86.5%-91.9%] had 1 reexcision, 48 [9.4%; 95% CI, 6.9%-12.0%] had 2 reexcisions, and 7 [1.4%; 95% CI, 0.4%-2.4%] had 3 reexcisions). Among all patients undergoing initial partial mastectomy, total mastectomy was performed in 190 patients (8.5%; 95% CI, 7.2%-9.5%). Reexcision rates for margin status following initial surgery were 85.9% (95% CI, 82.0%-89.8%) for initial positive margins, 47.9% (95% CI, 42.0%-53.9%) for less than 1.0 mm margins, 20.2% (95% CI, 15.3%-25.0%) for 1.0 to 1.9 mm margins, and 6.3% (95% CI, 3.2%-9.3%) for 2.0 to 2.9 mm margins. For patients with negative margins, reexcision rates varied widely among surgeons (range, 0%-70%; P=.003) and institutions (range, 1.7%-20.9%; PϽ.001). Reexcision rates were not associated with surgeon procedure volume after adjusting for case mix (P=.92). ConclusionSubstantial surgeon and institutional variation were observed in reexcision following partial mastectomy in women with invasive breast cancer.

The impact of county-level radiation oncologist density on prostate cancer mortality in the United States

“…Prostate cancer mortality and incidence data were obtained from a merged data set from the National Cancer Institute's Surveillance, Epidemiology and End Results program, National Program for Cancer Registries and United States Center for Disease Control and Prevention's National Vital Statistics System. 12 …”

Application of desorption electrospray ionization mass spectrometry imaging in breast cancer margin analysis

“…Preoperative mammography, ultrasonography, or MRI may be used by the surgeon to guide adequate resection (4)(5)(6). Despite numerous improvements in imaging and surgical technique, the need for reexcision to achieve complete tumor resection in the United States typically ranges from 20-40% (7)(8)(9)(10)(11)(12)(13)(14)(15), and has been reported as being as high as 60% (16). The importance of reexcision is underscored by numerous studies, which have shown that incomplete resection of tumor and positive margins are associated with increased locoregional recurrence compared with negative margins (12,(17)(18)(19)(20).…”

Radioactive Seed Localization for Nonpalpable Breast Lesions in a Community Hospital Setting

“…There is the potential for the wire to be displaced between the time of its image guided placement and subsequent removal in the operative suite. The surgical margins are frequently positive, which then requires an additional surgical procedure to remove more breast tissue to obtain clear margins (Cody & Van Zee, 2015;McCahill et al, 2012). A recent report from the National Cancer Database including 316, 114 patients undergoing breast conserving surgery from 2004 through 2010, demonstrated roughly one-fourth of patients required a second procedure (Wilke et al, 2014).…”