Author Insights: Much Variation Seen in How Frequently Additional Surgery After Lumpectomy Is Needed

In a new study, Laurence E. McCahill, MD, of Michigan State University in Grand Rapids, and his colleagues documented substantial variation in the rates of second surgeries among women undergoing lumpectomies at various hospitals. (Image: The Lacks Cancer Center at Saint Mary’s Health Care, in Grand Rapids, Michigan)

As many as two-thirds of women with breast cancer who have surgical treatment opt for removal of the affected tissue while preserving as much of the breast as possible, rather than undergo a complete mastectomy. Sometimes the patients who undergo lumpectomy may require additional surgery to remove more tissue, but a study published in JAMA today finds that the rates of such secondary breast cancer surgeries may vary considerably from hospital to hospital, raising questions about the reasons for such disparities.

Studies have demonstrated that lumpectomy or partial mastectomy offers many women with breast cancer the benefits of lifesaving treatment plus a better cosmetic outcome. But a potential risk of this treatment is that an estimated 30% to 60% of women who undergo this procedure will require additional surgery. Such repeat surgeries may take a physical, emotional, and financial toll on patients, so physicians and surgeons are eager to find ways to reduce the need for them. Doing so will require a detailed understanding of the many factors that contribute to the requirement for such “re-excisions.”

To help build such an evidence base, Laurence E. McCahill, MD, of Michigan State University in Grand Rapids, and his colleagues recently probed variations among surgeons or hospitals in the rate of such repeat surgeries for breast cancer. McCahill discussed his results with news@JAMA.

news@JAMA: Why do you think such variation in care exists?

Dr McCahill: There is a clear guideline for surgeons on when additional surgery is necessary if there is a tumor at the margin [of the surgical site]. But if the margins are clear but close, there is a tremendous amount of variation in opinion among surgeons. This is probably leading to quite a lot of variability in care women receive.

news@JAMA: What factors may contribute to variability?

Dr McCahill: The main things are probably technical factors, involving either the surgeon’s technique or how the surgeon coordinates with the pathologist at the hospital. Half is the process and half is probably opinion.

news@JAMA: What needs to be done to address such variation?

Dr McCahill: We need to get down to a more acceptable range of re-excision, down to 5% to 20% in the next 5 to 20 years. But I’m not trying to say re-excisions are bad. Surgeons are concerned about using re-excisions as a quality measure; we don’t want people to just take more [tissue during the initial surgery].

news@JAMA: What type of research is needed going forward?

Dr McCahill: I think these questions might best be answered with a large cohort study. It’s not just going to be about what margins are appropriate; it’s going to have to be about tumor biology and systemic treatments as well. It will be hard to answer these, but a cohort study might give us a high level of evidence.

news@JAMA: What are the clinical implications of your findings for patients?

Dr McCahill: Patients need to be as educated as possible about the importance of getting all of the tumor during the initial surgery and have a dialogue with their surgeon about how to best do that. After surgery, the patient should speak with her doctor about the pathology report from the postoperation evaluation and whether the results mean another surgery is necessary.

Categories: Breast Cancer, Evidence-Based Medicine, Surgery