25% reoperation risk after breast-conserving lumpectomy

1. Overall, about one in four women who underwent a breast-conserving lumpectomy for breast cancer treatment required repeat procedure.

2. Young age and large tumor size were among factors associated with a higher likelihood of requiring repeat surgery.

Evidence Rating Level: 1 (Excellent)      

Study Rundown: Breast Cancer is the most common cancer in women of all races, with more than 200,000 new cases diagnosed in the United States each year. In recent years, technology has advanced such that the 5-year survival is now nearly 90 percent. Multiple, high quality studies have demonstrated similar survival there following conservative lumpectomy, where just the tumor is removed versus the more radical surgical treatment of mastectomy, where the entire breast is removed. As such, the general consensus is that either is suitable surgical treatment for most invasive breast cancers. In preforming a lumpectomy, also known as breast-conserving surgery, the entirety of the tumor must be removed to reduce odds of recurrence. Many women require repeat surgery after the initial lumpectomy if microscopic evaluation demonstrates incomplete resection of tumor burden. However, the definition of a sufficient margin varies by physician. It was only earlier this year that The Society of Surgical Oncology and the American Society for Radiation Oncology developed guidelines adequate margins in stage I and II breast cancer. Since repeat surgeries cause significant adverse financial, psychological and cosmetic effects, adoption of a consensus definition would be valuable to permit minimizing unnecessary second surgeries. In this study, researchers used the National Cancer Database to examine factors associated with repeat surgeries after breast-conserving treatment.

In a large, national cohort, nearly 25% of women who underwent breast-conserving surgery later required repeat operation. Age, facility type and location and tumor size were all independent predictors of repeat surgery. Strengths of this study include a large, nationally representative sample size, covering 1400 institutions across the country. The National Cancer Database does not assess margin width, only definitive margin status (+/-), such that researchers were unable to evaluate width as a covariate or exposure variable. Future studies might also utilize a large multicenter database to prospectively examine future rates of repeat surgeries and assess how roll-out of the consensus guidelines as well as margin width impacts reoperation rate.

Click to read the study in JAMA Surgery

Click to read an accompanying editorial in JAMA Surgery

Relevant Reading: Margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer

In-Depth [retrospective cohort]: study included 316,114 women from the National Cancer Database with stage 0 to stage II breast cancer who underwent initial breast-conserving surgery from 2004-2010. The major outcome was incidence of repeat surgery. Patient, tumor and facility related variables were assessed and evaluated as predictors for repeat surgery.

Overall, 23.6 percent of patients underwent at least one additional surgery (n=74,517), of which 62.1 percent were completion lumpectomies and 37.9 percent were mastectomies. The proportion of repeat surgeries decreased slightly over the six-year study period, from 25.4% to 22.7% (p<0.001). Patients ages 18-29 were more likely to undergo repeat surgery compared with those over 80 (38.5% vs. 16.5%, p<0.001), as were those with larger tumors (p<0.001).

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