The possibility of reexcision after breast-conservation surgery should be discussed with patients before the initial surgery, advised Laurence E. McCahill, MD, lead investigator of the JAMA study on reexcision following breast-conservation surgery, which showed wide variability in reexcision rates.¹ “It is worth having the dialogue ahead of time in terms of what we are trying to achieve surgically,” so that patients have an understanding of margins and their significance, he said.

“We have good data at this point in terms of how often people get positive margins. It varies, but I think it is fairly safe to say that positive margins seem to occur between 10% and 20% of the time in  various studies. Those are situations where you would almost anticipate having to reoperate.” Patients should understand that “having close or even sometimes positive margins is, in some circumstances, unavoidable,” Dr. McCahill said. “We would like to minimize it, but sometimes we can’t.

After the surgery, Dr. McCahill suggests reviewing the pathology report with patients. “I give my patients a copy of their pathology report,” he said. “I think the more empowered women are, the more they are knowledgeable about their disease, then the more likely they are to get better health care, as opposed to just sitting back and thinking the doctor has it right all the time.”

May Opt for Total Mastectomy

Raising the possibility of reexcision ahead of time could reduce the sense of alarm that can arise when patients are told they need a second surgery. “In a significant number of cases, the second operation is a mastectomy,” Dr. McCahill said. “Sometimes that may be clinically indicated, but other times I think it is due to alarm, frustration, or lack of awareness that reexcision—a second partial mastectomy—may very well be appropriate and able to achieve the original outcome of desire: breast conservation with adequate clear margins.” In the JAMA study, 190 patients (8.5%) of the 2,206 who had initial partial mastectomies subsequently had total mastectomies.

Although the authors do not suggest that patients select surgeons or institutions on the basis of their reexcision rates, the study and the many press reports may prompt patients to ask about those rates. Dr. McCahill said that would be a fair question. “I’m not opposed to people asking me,” Dr. McCahill said. “In fact, I get asked all the time, ‘What is your complication rate for major surgery?’ or ‘How many of these surgeries have you done?’” ■

Reference

1. McCahill LE, Single RM, Aiello Bowles EJ, et al: Variability in reexcision following breast conservation surgery. JAMA 307:467-475, 2012.