Study reveals ‘quite high’ re-excision rates after initial breast-conserving surgery
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A higher-than-expected percentage of women with breast cancer who underwent breast-conserving surgery underwent re-excision within a year, according to retrospective findings published in Annals of Surgical Oncology.
“High reoperation rates have been an issue since 2014, when the Society of Surgical Oncology-American Society for Radiation Oncology issued consensus guidelines on surgical margins for breast-conserving surgery,” researcher Youngran Kim, PhD, assistant professor of management, policy and community health at University of Texas Health Science Center at Houston, told Healio.
“After those guidelines were released, the reoperation rate decreased in a significant number of patients,” Kim added. “However, we wanted to know whether these efforts to decrease reoperation rates continued after the publication. We wanted to provide a more comprehensive and current understanding of reoperation rates.”
Ideally, reoperation rates should be closer to 5%, according to investigators. This takes into account cases when extent of disease may be underestimated on imaging findings and other factors that could result in positive margin on final pathology.
Kim and colleagues analyzed data on more than 24,000 women with breast cancer who underwent breast-conserving surgery.
Results showed more than one in five (21.1%) commercially insured women and about one in seven (14.9%) Medicare beneficiaries underwent re-excision within a year. Reoperations increased risk for complications and also resulted in considerably higher costs, results showed.
Healio spoke with Kim about the findings, their implications, and how patients and providers can work toward reducing reoperation rates.
Healio: How did you conduct this study?
Kim: We used the commercial insurance and Medicare datasets, and identified women who underwent initial breast-conserving surgery for breast cancer between 2017 and 2019. The cohort included 17,129 commercially insured women aged 18 to 64 years, as well as 6,977 Medicare beneficiaries aged 18 years or older. We evaluated the rates of reoperation after breast-conserving surgery. We then estimated these patients’ health care costs within a 1-year period. We also reviewed complication rates and the extent to which these were associated with reoperation.
Healio: What did you find?
Kim: Reoperation rates continue to be quite high. Reoperations decreased with increasing age, and switching to mastectomy was more common among younger women in the commercial cohort. Re-excisions were associated with 24% higher costs in both groups, equating to $21,607 in incremental costs in the commercial cohort and $8,559 in incremental costs in the Medicare cohort.
Additionally, we found higher reoperation rates among those with ductal carcinoma in situ (DCIS) vs. invasive cancer. Overall, younger women with DCIS had the highest risk for reoperation at about 40%.
Reoperation was associated with a 54% increase in risk for complications in the commercial cohort and an 89% increased risk for complications in the Medicare cohort.
Healio: Why do you think re-excision rates are higher than they should be?
Kim: There appears to be wide variation across providers and/or institutions in reoperation rates. We hypothesize that there is a notable variation in practice, perhaps indicating a slower adoption of the 2014 guidelines by some providers.
Healio: What can be done to reduce reoperation rates?
Kim: On the provider side, we encourage the practice of following the guidelines and improving the intraoperative assessment of margins using real-time techniques. This may have the potential to reduce the rates of reoperation. Also, patients are encouraged to choose providers with more optimal reoperation rates when deciding on breast-conserving surgery.
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For more information:
Youngran Kim, PhD, can be reached at University of Texas Health Science Center Houston, Reuel Stallons Building E1207, 1200 Pressler St., Houston, TX 77030; email: youngran.kim@uth.tmc.edu.
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