Target Audience (click to view)
This activity is designed to meet the needs of physicians.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Describe the findings of a study that examined women who underwent initial breast conservation surgery to determine the proportion who received a subsequent partial mastectomy or mastectomy.
Method of Participation(click to view)
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwDec5. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. at firstname.lastname@example.org.
Credit Available(click to view)
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
AKH planners and reviewers have no relevant financial relationships to disclose.
Take CME(click to view)
Previous long-term research has found that there appears to be no difference in disease-free or overall survival between partial and total mastectomy for the treatment of invasive breast cancer. Despite these studies, substantial controversy remains regarding the definition of being free of tumor. “Until recently, no guidelines were available that described an adequate margin width for invasive or non-invasive breast cancer,” explains Lee G. Wilke, MD, FACS. “This lack of consensus has led to significant variations in reexcision rates for these patients.” She adds that the financial, psychological, and cosmetic effects of these repeat surgeries are important to patients and increase the burden of breast cancer therapy.
Identifying Key Determinants
In a study published in JAMA Surgery, Dr. Wilke and colleagues examined women who underwent initial breast conservation surgery (BCS) to determine the proportion that received a subsequent partial mastectomy or mastectomy. The study included more than 316,000 patients with stage 0 to II breast cancer who underwent initial BCS. Patients who were neoadjuvantly treated or whose conditions were diagnosed by excisional biopsy were excluded from the analysis. Information was collected from the National Cancer Data Base (NCDB), a large observational database of accredited cancer centers from the Commission on Cancer that contains data on more than 70% of patients treated for cancer in the U.S. The NCDB afforded an opportunity to observe differences among patient, tumor, and facility groups that were associated with repeat surgeries.
“Our results showed that about one-quarter of patients undergoing an initial BCS had at least one additional operation,” Dr. Wilke says. About two-thirds of this group had a complete lumpectomy while the remaining one-third received a mastectomy. The proportion of patients undergoing repeat surgery decreased only slightly during the 6-year study period. Several independent predictors of repeat surgeries were identified. These included age, race, insurance status, comorbidities, histologic subtype, estrogen receptor status, pathologic tumor size, node status, tumor grade, facility type and location, and volume of breast cancer cases.
Exploring Important Trends
The volume of breast cancer cases was minimally associated with repeat surgery rates unless high-volume institutions were examined. High-volume centers were 16% more likely to perform repeat surgeries than low-volume institutions. They were also more likely to be academic facilities. The authors noted that the repeat surgery rates observed among high-volume institutions may reflect patient referral patterns.
In addition, significant variations were observed in repeat surgery rates depending on the patient’s location in the country (Figure 1). Repeat surgeries were most common at facilities located in the Northeast when compared with facilities in the Mountain region. Academic or research facilities had a 26% repeat surgery rate, compared with a rate of slightly more than 22% that was seen at community facilities.
Researchers also found that the repeat surgery rate was nearly 39% for patients aged 18 to 29, compared with a nearly 17% rate that was seen among patients aged 80 and older. Larger tumor size was associated with a higher likelihood of repeat surgery. For tumors smaller than 1.5 cm, the repeat surgery rate was about 21%, compared with a repeat surgery rate of approximately 48% for tumors larger than 5 cm (Figure 2). In a multivariate regression analysis, patients with 2 cm to 5 cm tumors were 23% more likely to undergo repeat surgeries than those with tumors smaller than 2 cm.
More Work Needed
“Our data gives clinicians a starting point to begin improving rates of repeat surgery in breast cancer,” says Dr. Wilke. “One way to improve these rates is through standardization of an acceptable margin width as well as radiological and pathological processing of a BCS specimen.” The tumor margin width that can provide the lowest local recurrence rate has not been established in randomized controlled trials but has been evaluated via a large meta-analysis. Clinician should begin to implement use of the standard definitions of adequate margins as set in consensus guidelines by the Society of Surgical Oncology and the American Society for Radiation Oncology.
Dr. Wilke adds that clinicians need to incorporate the currently available consensus guidelines and conduct outcomes analyses of these recommendations to document a decrease in their own repeat surgery rates. “Our data should be used to better inform patients and providers about repeat surgery rates and how patient or tumor characteristics influence these rates,” she says. Through quality improvement projects, adoption of consensus margin guidelines and standardization of margin assessment, it is anticipated that the wide variation in repeat surgery rates will decrease as will the costs and patient anxiety surrounding tumor-positive margins.
Readings & Resources (click to view)
Wilke LG, Czechura T, Wang C, et al. Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a: : a report from the National Cancer Data Base, 2004-2010. JAMA Surg. 2014;149:1296-1305. Available at: http://archsurg.jamanetwork.com/article.aspx?articleid=1921614.
Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of re-excision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol. 2008;15:1297-1303.
Lovrics PJ, Cornacchi SD, Farrokhyar F, et al. Technical factors, surgeon case volume and positive margin rates after breast conservation surgery for early-stage breast cancer. Can J Surg. 2010;53:305-312.
Moran MS, Schnitt SJ, Giuliano AE, et al; Society of Surgical Oncology; American Society for Radiation Oncology. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. J Clin Oncol. 2014;32:1507-1515.