Trends in Surgery After Initial Lumpectomy for Breast Cancer

Key Points

  • The rate of surgery after initial lumpectomy decreased by 16% between 2013 and 2015.
  • Surgeons with a higher case volume were more likely to endorse “no ink on tumor” as an adequate surgical margin.

In a study reported in JAMA Oncology, Morrow et al found that the rates of surgery after initial lumpectomy for stage I or II breast cancer have decreased with dissemination of guidelines advocating a minimal negative surgical margin. A 2014 consensus statement of the Society of Surgical Oncology and American Society of Radiation Oncology recommended use of “no ink on tumor” as the definition of clear margin in patients receiving breast-conserving surgery and radiotherapy.

Study Details

The population-based cohort survey study involved data from women aged 20 to 79 years with stage I or II breast cancer diagnosed in 2013 to 2015 and identified from the Georgia and Los Angeles County Surveillance, Epidemiology, and End Results registries. Among respondents, those with bilateral disease, missing stage or treatment data, or ductal carcinoma in situ were excluded from analysis, leaving a total of 3,729 in the study population; 98% of these identified their surgeon. Between April 2015 and May 2016, 342 surgeons responded to surveys regarding lumpectomy margins.

Trends in Additional Surgery

Overall, 2,509 patients (67%) had an initial lumpectomy, with the rate of initial lumpectomy not changing over the study period after adjustment for covariates (odds ratio [OR] for 1 quarter change = 1.03, P = .10). Final surgical treatment was lumpectomy in 63%, unilateral mastectomy in 21%, and bilateral mastectomy in 17%. From 2013 to 2015, rates of lumpectomy with reexcision and lumpectomy with subsequent mastectomy decreased from 21% and 13% to 14% and 4% (P < .001), with an overall rate of surgery after initial lumpectomy declining by 16%. Pathology review documented no significant association between the date of treatment and positive margins.

Among surgeons, 69% and 63% endorsed a margin of no ink on tumor to avoid reexcision in estrogen receptor–positive, progesterone receptor–positive cancer and estrogen receptor–negative, progesterone receptor–negative cancer, respectively. Surgeons treating more than 50 patients with breast cancer annually were more likely to endorse this margin compared with those treating up to 20 (85% vs 55%, P < .001).

The investigators concluded: “Additional surgery after initial lumpectomy decreased markedly from 2013 to 2015 concomitant with dissemination of clinical guidelines endorsing a minimal negative margin. These findings suggest that surgeon-led initiatives to address potential overtreatment can reduce the burden of surgical management in patients with cancer.”

The study was funded by a grant from the National Cancer Institute.

Monica Morrow, MD, of Memorial Sloan Kettering Cancer Center, is the corresponding author of the JAMA Oncology article.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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