Risk Of Re-excision Research Articles

Re-excision rates among older breast cancer patients undergoing breast-conserving surgery (BCS): Impact of the SSO-ASTRO consensus guideline on margins.

576 Background: BCS has been historically associated with a high re-excision rate, driven in part by the need of obtaining negative margins. The SSO-ASTRO consensus guideline on invasive margins, defined a negative margin as no ink on tumor. In this large population-based study of older breast cancer patients undergoing BCS for invasive breast cancer we evaluate the guideline impact on re-excision rates. Methods: Female patients diagnosed with stage I-II breast cancer between 2012-2015 were identified in the SEER-Medicare database. Patients were >66 years and underwent BCS. Patients treated with neoadjuvant chemotherapy were excluded. We defined the following time periods: pre-guideline (January 2012-September 2013); peri-guideline (October 2013-March 2014) and post-guideline (April 2014-December 2016). Re-excision was defined as a resection, BCS or mastectomy identified using ICD-9 or CPT codes between 4 and 90 days after initial BCS. Overall re-excision rates and 95%CI were calculated and groups compared using X2test. Within subgroups we calculated re-excision rates for the pre and post-guideline periods and report the relative percent change. Regression model evaluated the association between time periods and re-excision while adjusting for important covariates, risk ratios (RRs) and 95%CI are presented. Results: 17001 patients were included. 6762 of them had BCS in the pre, 1786 in the peri, and 8453 in the post-guideline periods. Overall 22.6% of the patients had a re-excision. The rate decreased from 24.8% pre-guideline to 20.3% post-guideline (P < 0.001). The relative change in re-excision varied according to region (Midwest 3-7.3%, Northeast -20%, West -16.5% and South -13.5%) Differences in the relative change according to race/ethnicity were also seen (Whites -19.2, Blacks -15.3% and Hispanics -9.9%). In the multivariable model, BCS in the post-guideline period was associated with a decreased risk of re-excision (RR = 0.83; 95%CI 0.79-0.88). Lobular histology was associated with a higher risk of re-excision (RR = 1.31; 95%CI 1.21-1.42); greater surgeon volume was associated with lower risk of re-excision (RR = 0.89; 95%CI 0.82-0.95). Conclusions: There has been a statistically significant decrease in the re-excision rate after BCS associated with the dissemination of the SSO-ASTRO consensus guideline on invasive margins. Our study confirms the impact that guidelines have modifying patterns or practice, reducing the frequency of unnecessary interventions.

Abstract P2-12-10: Does breast density increase the risk of re-excision for women with breast cancer having breast conservation therapy?

Abstract Background The definition of an adequate surgical margin for breast cancer has been a hotly debated topic for over 20 years, with “no ink on tumor” now widely recognized as an adequate pathological margin for invasive carcinoma. Patients with dense breasts pose unique challenges in terms of accurate pre-operative evaluation of extent of disease and achieving adequate margins at initial surgery. The aim of this study therefore is to analyze re-excision rates and correlate with breast density and other clinical and pathological factors before and after the decision to accept 'no tumor at the inked margin” as an adequate margin. Methods Patients with stage I or II invasive breast cancer treated with breast conserving surgery between the 1st of June 2013 and the 31st of October 2014 were included. Patients who had surgery prior to January 1, 2014 comprise the pre-guideline group whereas those who had surgery on or after January 1, 2014 comprise the post-guideline group. Breast density was assessed by 2 independent radiologists. Inter-reader agreement was assessed using data on all study subjects and intra-reader agreement was assessed on a random sample of 121 study subjects; agreement was assessed using the kappa statistic with bootstrap confidence intervals. Logistic regression was used to model the association between breast density and re-excision, using the minimum value of breast density according to the two independent readers, within the 2 time periods. Multivariable logistic regression adjusted for patient and disease characteristics associated with re-excision on univariable analysis. Results The inter-reader agreement was 0.633 (95% confidence interval (CI): 0.604, 0.663) whereas the intra-reader agreement was 0.755 (95% CI: 0.663, 0.834). A total of 1205 patients were included, of whom 504 (41.8%) had surgery before the guideline change and 701 (58.2%) after. Overall 214 (17.8%) had at least one re-excision. The re-excision rate was significantly lower in the time period after the guideline change (15.1% verus 21.4%, p=0.006). There was no significant difference in tumor characteristics between the time periods. Younger age at diagnosis was the only clinicopathological factor that was significantly associated with increased breast density (p<0.001). On univariable analysis, increased breast density was associated with higher risk of re-excision (p=0.005), as was younger age, multifocality, presence of DCIS, HER2 status and extensive intraductal component (EIC). On multivariable analysis, time period, age at diagnosis, multifocality, presence of DCIS and EIC were significantly associated with re-excision, but breast density was not (OR 1.24, 95% CI 0.98-1.56, p=0.07). Conclusions Women who are of younger age at diagnosis are more likely to have increased breast density. Although, younger age was associated with higher rate of re-excision, we did not find breast density to be associated with a higher rate of re-excision on multivariable analysis. Citation Format: Walsh SM, Brennan SB, Zabor E, Rosenberger LH, Stempel M, Lebron-Zapata L, Gemignani ML. Does breast density increase the risk of re-excision for women with breast cancer having breast conservation therapy? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-10.

Breast cancer presentation and therapy in migrant versus native German patients: contrasting and convergent data of a retrospective monocentric study

The aim of this study was to identify differences between breast cancer patients with and without migrant background in Germany, especially differences concerning patient characteristics, tumor biology, diagnostics, therapy, and oncological outcome. In 99 breast cancer patients (composed of 50 native, randomly selected Germans and 49 consecutively selected immigrants of Anatolian origin) who were operated due to breast cancer at the Heidelberg University Hospital between the years 2009-2012, relevant information was retrospectively reviewed. Patients with migrant background were significantly younger at the time of receiving the diagnosis of breast cancer than native German patients with an average age difference of nine years (p<0.001). Moreover, immigrants needed a second operation for re-excision more frequently than native Germans (45 vs. 20%, p=0.01). The medication used for hormone therapy was significantly different between the two cohorts (p=0.049). Although statistically not significant, a tendency towards difference was observed in six characteristics examined: Premenopausal status, estrogen receptor-positive tumors, multifocal or bilateral tumors, BRCA-1 mutations, and an accompanying carcinoma in situ were more common in patients with migrant background. On the other hand, correspondence was found between both patient groups relating to tumor staging, grading and metastasis as well as surgical, drug, and radiologic therapies employed. Oncologic outcome data were not different either. A difference in age between breast cancer patients of diverse ethnic groups has already been described previously. The difference in the frequency of surgical re-excision might be explained by several factors like a young age at first diagnosis, premenopausal status, multifocal tumors and an accompanying carcinoma in situ which were more common in the migrant patients of this study and are known to increase the risk of re-excision. The medication used for hormonal therapy was also different between migrants and native Germans, which might be interpreted by the difference in patients' age and menopausal status. Of note, however, in the present study, the overall breast cancer outcome did not show any substantial disparity between the different ethnic patient groups investigated.

Accuracy of radiological tumour size assessment and the risk for re-excision in a cohort of primary breast cancer patients

Background Re-operations after breast conserving surgery (BCS) are necessary, when specimen margins are not free of breast cancer cells. This study explored the accuracy of preoperative tumour size assessment and its influence on the rate of re-excisions and mastectomies. Methods The study included 1591 patients with invasive breast cancer, who were planned for BCS. Patient, staging and tumor characteristics were evaluated concerning their influence on re-excision and mastectomy rates. Patient and tumor characteristics comprised histopathological tumour size, HER2 status, multifocality, in situ component, grading (G), nodal status and hormone receptor (HR) status. Staging characteristics included deviation from pathological tumour size as measured by clinical examination, sonography and mammography. Results In 1316 patients (83%) sufficient treatment was possible with one operation. 275 patients (17%) had to undergo at least one further surgery as a result of positive specimen margins. In 138 patients (9%) mastectomy was ultimately necessary. In patients with a positive HER2 status, a larger tumour size, underestimation by ultrasound, an in situ component and multifocality, the risk for a re-operation was about doubled. Tumour size deviation in the mammogram or the clinical tumour size assessment did not have significant influence to the re-excision rates. Conclusion Tumour size and accurate presurgical assessment of the tumour size itself are independent predictors for the need of a second surgery or even a mastectomy in patients for whom a primary BCS was planned.

Assessing the Public's Preference for Surgical Treatment of Primary Basal Cell Carcinoma: A Discrete-Choice Experiment in the South of The Netherlands

Basal cell carcinoma (BCC) is a slowly growing nonmelanoma type of skin cancer that often is located on the face. Different therapies are available to treat BCC, of which surgical excision (SE) and Mohs micrographic surgery (MMS) are the most frequently used surgical procedures. To examine which attributes of a surgical treatment the general public values as important and to determine the incremental willingness to pay for MMS versus SE. A discrete-choice experiment (DCE) was conducted among members of the general public to examine which attributes of a surgical treatment for primary BCC are valued as important. In addition, based on the attributes included in the experiment, the willingness to pay for MMS versus SE was determined. Respondents (N=312) preferred a treatment with a lower recurrence rate, shorter surgery time, shorter travelling time, shorter waiting time, no risk for re-excision, and lower cost. The incremental willingness to pay for MMS was 847 euro ($1,203). Results from this DCE indicate that, when outcome and process attributes are considered from a societal perspective, MMS is preferred over SE for primary BCC. The authors have indicated no significant interest with commercial supporters.

Positive Margins: The Challenge Continues for Breast Surgeons

Positive Margins: The Challenge Continues for Breast Surgeons

Mammographic density has an impact on the risk for re-excision after breast conserving surgery of primary breast cancer

Objective: Aim of our study was to evaluate the impact of mammographic density on the risk for a re-excision.

SUBSEQUENT SURGERY AFTER INITIAL BREAST CONSERVING SURGERY: A POPULATION BASED STUDY

In line with current Australian early breast cancer management guidelines, more women are having breast conserving surgery to treat breast cancer when appropriate. Some women will undergo further surgery because of involved margins, early local relapse, or other factors including patient choice. The aim of this study was to investigate whether socio-economic, demographic or hospital factors were associated with the risk of re-excision or subsequent mastectomy. A record linkage population-based study on 12 711 women diagnosed with breast cancer in Western Australia from 1982 to 2000 who underwent breast surgery within 12 months of diagnosis was performed. Logistic regression was used to identify social, demographic and hospital factors associated with the risk of undergoing further surgery following initial breast conserving surgery. The proportion of women undergoing initial breast conserving surgery doubled from 33% in 1982-1985 to 72% in 1998-2000. The proportion of women who underwent further surgery following initial breast conserving surgery decreased from 50 to 30% over the same period. The risk of re-excision or subsequent mastectomy was between 2.4 (95% CI 1.7-3.4) and 5.0 (95% CI 3.4-7.4) times greater if initial surgery was performed in a non-metropolitan hospital compared to Perth hospitals. Younger women were between 1.7 (95% CI 1.4-2.0) and 2.1 (95% CI 1.5-3.0) times more likely to undergo re-excisions compared to women aged 50-64 years of age. Young women and women initially treated in non-metropolitan hospitals were at an increased risk of re-excision or a subsequent mastectomy following initial breast conserving surgery to treat breast cancer. Efforts need to be directed towards improving specialist health services outside of Perth if women continue to be treated for breast cancer in non-metropolitan hospitals.