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Post-lumpectomy surgery rates for invasive breast cancer have declined
CHICAGO — The rate of additional breast cancer surgery after initial lumpectomy declined by 16% since 2014, according to results of a population-based study presented at the ASCO Annual Meeting.
Monica Morrow, MD, chief of the breast surgery service at Memorial Sloan Kettering Cancer Center, and colleagues linked this decrease with the Society of Surgical Oncology–American Society for Radiation Oncology consensus guideline for minimal negative margin for invasive breast cancer on post-lumpectomy surgery and final surgical treatment.
“Our findings suggest that evidence-based multidisciplinary guidelines addressing clinical controversy can be an effective, low-cost approach to accelerating practice change,” Morrow said during her presentation.
Surgery after initial lumpectomy is commonly performed to obtain a wider negative margin in invasive breast cancer, but can lead to mastectomy.
Morrow and colleagues sought to examine surgeon attitudes, re-excision rate and final surgical procedure following the publication of the minimal negative margin as a multidisciplinary guideline.
Researchers surveyed 7,303 patients diagnosed with stage I and II breast cancer from the Los Angeles and Detroit SEER registries who were set to undergo lumpectomy between July 2013 and August 2015. Researchers also reviewed pathology reports to determine margin status.
A total of 3,729 patients (62% aged 50-69 years; 54% white) comprised the analytic sample.
Researchers reported an initial lumpectomy rate of 67%, which did not change throughout the study.
From April 2013 to April 2015, the final lumpectomy rate increased by 13% — from 52% to 65% — accompanied by a decrease in unilateral mastectomy (27% to 18%) and bilateral mastectomy (21% to 16%; P = .002).
The number of re-excision surgeries after lumpectomy decreased from 21% to 14% and mastectomy decreased from 13% to 4% (P < .001). A pathology review indicated date of treatment was not associated with positive margins.
The number of surgeon-recommended mastectomies after initial lumpectomy decreased from 20% to 8% (P < .001), according to patient reports.
Researchers sent all attending surgeons identified by the patients (n = 489) a questionnaire at the end of the patient survey period. Of these, 376 (77%) responded.
Among the surgeons, 85% endorsed a margin of no ink on tumor to avoid re-excision in ER– and PR–positive breast cancer, and 78% for ER– and PR–negative breast cancer.
Survey responses also indicated that surgeons who treated more than 50 breast cancers annually appeared more likely to accept the margin than surgeons who treated fewer than 20 cases (P < .001).
Morrow attributed the decrease in surgeries to the guideline adoption due to certain findings in the study.
“We know these changes are due to the guideline adoption because there was no change in patient attitudes or clinical factors; more than two thirds of surgeons endorse no ink on tumor; and in 617 ductal carcinoma in situ patients having lumpectomy in the same period, [there was] no change in post-lumpectomy surgery,” Morrow said. – by Melinda Stevens
Reference:
Morrow M, et al. Abstract 508. Presented at: ASCO Annual Meeting; June 2-6, 2017; Chicago.
Disclosure: Morrow reports honoraria from Genomic Health. Please see the abstract for a list of all other researchers’ relevant financial disclosures.
Perspective
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Breast conservation surgery with radiation has equivalent survival benefit in early-stage breast cancer to mastectomy. As such, it is a standard of care for most women with early-stage breast cancer. Prior to 2014, there was wide variability in the acceptable width of margins for breast conservation. Society of Surgical Oncology–American Society for Radiation Oncology Margin Consensus published in 2014 stated that the definition of a negative margin is no tumor at ink. Essentially this meant that, provided there is no tumor at ink, this is considered a negative margin and there is no need for a re-excision. This was a paradigm shift in breast conservation because prior to this, there was no standard margin width supported by data. Re-excision in breast conservation potentially results in decreased aesthetic appearance of the breast, and can delay systemic therapy and radiotherapy.
There are many surgeons who were initially slow to adopt these guidelines. The study by Morrow and colleagues evaluated the impact of the 2014 consensus statement on the final surgical procedure. Although the initial lumpectomy rate did not change, the final lumpectomy rate increased by 13%. Conversely, the final mastectomy rate decreased. This occurred because surgeons adopted the guidelines and, therefore, the number of patients undergoing re-excisions decreased. In our own practice, we have seen a decrease in re-excision rates since adopting the margins consensus for invasive disease.
Another important finding is that surgeons treating more than 50 breast cancers per year were more likely to accept the margin consensus than those treating fewer than 20 cases per year. Data-driven consensus statements such as the SSO–ASTRO Margin Consensus guideline ultimately have a positive impact on the overall care of patients.
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