Opportunities to reduce reoperations and to improve inter-facility profiling after initial breast-conserving surgery for cancer. A report from the NCDB

BackgroundRepeat operations after breast-conserving surgery (BCS) for cancer have been termed “epidemic.” To aid improvement activities, we sought to identify those National Cancer Data Base (NCDB) characteristics that were associated with reoperations.MethodsA retrospective cohort of patients with invasive breast cancer undergoing initial BCS in the NCDB from 2004 to 2015 were identified. Univariate, multivariate, ranking (effect size and R²), and time-trend methods were used to assess associations between patient, facility, tumor, treatment, and calendar-year characteristics with reoperation.ResultsIn 1226 facilities, 84,462 (16.1%) of 524,594 patients underwent reoperations after BCS [range 0–75%; 10th/90th performance percentiles = 6.6%/25%]. Of 18 factors associated with reoperations, facility ID was the highest-ranked. Its estimated impact on the odds of reoperation was more than 10 times greater than any other factor considered, followed by tumor size, neo-adjuvant chemotherapy receipt, patient age, cancer histology, and nodal status. Reoperations after the year of the SSO-ASTRO margin guideline declined significantly compared with prior years. Significant inter-facility reoperation variability persisted after risk adjustment for more than a dozen distinct patient, facility, tumor, and treatment characteristics.ConclusionIn the NCDB, significant inter-facility variability exists regardless of case volume, case mix, and risk adjustment. There were fewer reoperations after the SSO-ASTRO guideline. An endorsed target rate of 10% was achieved by only 1 in 4 facilities. The most impactful determinant of reoperation was the facility itself. Thus, all stakeholders should consider participation in improvement activities. Such activities will benefit from risk-adjusted profiling; the relevant adjustors were identified.     

Optimization of Wire-guided Technique With Bracketing Reduces Resection Volumes in Breast-conserving Surgery for Early Breast Cancer

BackgroundWire-guided localization (WGL) of early breast cancer can be facilitated using multiple wires, which is called bracketing wire-guided localization (BWL). The primary aim of this study is to compare BWL and conventional WGL regarding minimization of resection volumes without compromising margin status. Secondly, BWL is evaluated as an alternative method for intraoperative ultrasound (US) guidance in poorly definable breast tumors on US.Patients and MethodsIn this retrospective cohort study, patients with preoperatively diagnosed breast cancer undergoing wide local excision between January 2016 and December 2018 were analyzed. Patients with multifocal disease or neoadjuvant treatment were excluded from this study. Optimal resection with minimal healthy breast tissue removal was assessed using the calculated resection ratio (CRR).ResultsBWL was performed in 17 (9%) patients, WGL in 44 (22%), and US in 139 (70%). The rate of negative margins was comparable in all 3 groups. The CRR was significantly smaller for BWL (0.6) than WGL (1.3) in tumors larger than 1.5 cm. Additionally, BWL (0.8) led to smaller CRRs than US (1.7). This could be explained by the high number of small tumors (≤ 1.5 cm) in the US group for which greater CRRs are obtained than for large tumors (> 1.5 cm) (1.9 vs. 1.4; P = .005).ConclusionFor breast tumors larger than 1.5 cm, BWL achieves more optimal resection volumes without compromising margin status compared with WGL. Moreover, BWL seems a suitable alternative to US in patients with poorly ultrasound-visible breast tumors and patients with a small tumor in a (large) breast.     

Breast conservation therapy versus mastectomy in the community-based setting: can this rate be used as a benchmark for cancer care?

Despite strong evidence supporting the use of breast conservation therapy (BCT) in the treatment of breast carcinoma, the actual rates of use remain low. This article is a retrospective review of a sample of patients from the cancer registry of the Carolinas Medical Center (CMC), comparing breast conservation and mastectomy rates during an 11-year period. BCT rates have increased in CMC during this time frame and have reached national levels. Further research is needed to determine whether BCT rates can be used as a benchmark for the care of patients with cancer.     

Different annual recurrence pattern between lumpectomy and mastectomy: implication for breast cancer surveillance after breast-conserving surgery

Purpose.

To investigate the recurrence pattern and annual recurrence risk after breast-conserving surgery and compare them with those after mastectomy.

Methods.

This retrospective analysis included 6,135 consecutive unilateral breast cancer patients undergoing surgery in 1998–2008, with 847 lumpectomy patients and 5,288 mastectomy patients. Recurrence patterns were scrutinized and annual recurrence rates were calculated. Furthermore, a literature-based review including seven relevant studies was subsequently performed to confirm our single-institution data-based observations.

Results.

After lumpectomy, 50.9% of recurrences occurred within 3 years and 30.2% of recurrences were detected at 3–5 years; after mastectomy, 64.9% of recurrences occurred within 3 years and 20.4% occurred at 3–5 years. The major locoregional recurrence pattern after lumpectomy was ipsilateral breast tumor recurrence, which mainly (81.3%) occurred ≤5 years postsurgery but with a low incidence of 37.5% ≤3 years postsurgery. Annual recurrence curves indicated that the relapse peak after mastectomy emerged in the first 2 years; however, recurrence after lumpectomy increased annually with the highest peak near 5 years. By reviewing relevant studies, we confirmed our finding of different annual recurrence patterns for lumpectomy and mastectomy patients. The hazard ratio of dying for those recurring ≤5 years postlumpectomy relative to patients relapsing >5 years postlumpectomy was 4.62 (95% confidence interval, 1.05–20.28; p = .042).

Conclusions.

Different recurrence patterns between mastectomy and lumpectomy patients imply that scheduling of surveillance visits should be more frequent during the 4–6 years after lumpectomy. Further prospective trials addressing the necessity of frequent and longer surveillance after lumpectomy are warranted.     

Current status of radioactive seed for localization of non palpable breast lesions

Background

Wire-localized breast biopsy (WLBB) remains the standard method for the surgical excision of nonpalpable breast lesions. Because of many of its shortcomings, most important a high microscopic positive margin rate, alternative approaches have been described, including radioactive seed localization (RSL). This review highlights the literature regarding RSL, including safety, the ease of the procedure, billing, and oncologic outcomes.

Methods

Medline and PubMed were searched using the terms “radioactive seed” and “breast.” All peer-reviewed studies were included in this review.

Conclusions

RSL is a promising approach for the resection of nonpalpable breast lesions. It is a reliable and safe alternative to WLBB. RSL is at least equivalent compared with WLBB in terms of the ease of the procedure, removing the target lesion, the volume of breast tissue excised, obtaining negative margins, avoiding a second operative intervention, and allowing for simultaneous axillary staging.     

Breast tattoos for planning surgery following neoadjuvant chemotherapy

BACKGROUND: Although neoadjuvant chemotherapy is increasingly used for breast cancer, if a patient has a complete clinical response, it is often difficult for the surgeon to know exactly where and how much breast tissue to remove. METHODS: A method is described where the edges of the tumor are tattooed prior to chemotherapy, allowing all tissue initially involved with tumor to be resected following the chemotherapy. RESULTS: Thirty-four cases have been tattooed prior to neoadjuvant chemotherapy, and the clinical and pathological complete response rates were 56% and 22%, respectively. The tattoos allowed very accurate localization of the residual tumor location and extent. Of the 22 patients who have so far undergone lumpectomy, 77% had residual pathologic evidence of tumor, but the margins were negative in 91% at the first operation. Only 2 patients had to undergo a mastectomy because of persistently positive margins. CONCLUSIONS: The technique of breast tattooing is a simple and practical method to guide the extent of breast surgery following neoadjuvant chemotherapy. In contrast to placement of clips, the technique does not require needle localization, and it allows accurate determination of the initial tumor size and margins.     

A device for real-time, intraoperative margin assessment in breast-conservation surgery

BACKGROUND: This trial was designed to study performance of a novel handheld probe (Dune Medical Devices, Caesarea, Israel) in intraoperative detection of positive margins and its potential benefit toward minimizing the positive margin rate. METHODS: The probe was intraoperatively applied to 57 lumpectomy specimens. Surgeons were blinded to device output, and surgical decisions were not affected by probe data. Probe readings were compared with histological analysis per margin and per patient. RESULTS: Nineteen of 22 (86%) pathology-positive patients were intraoperatively detected with device use. Per-margin sensitivity was .71, and specificity was .68, maintained within a range of positive margin definitions (0-.4 cm). CONCLUSIONS: The device is an effective tool for intraoperative detection of positive margins with the potential for significant positive margin rate reduction.