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Re-operation common after breast-conserving surgery

Last Updated: 2012-01-31 16:00:31 -0400 (Reuters Health)

By Genevra Pittman

NEW YORK (Reuters Health) - One in four women who have breast-conserving surgery for cancer needs a second operation to remove more breast tissue, suggests a new study that also found the rate of re-operation varied widely by surgeon.

Researchers said the goal shouldn't be to never do a repeat surgery, which might cause surgeons to take out too much tissue the first time around, or to avoid operating again on women who need it.

Still, very high rates of re-operation mean some of those surgeries might be unnecessary, or could be prevented.

"I don't think it's so great to put a patient through an operation and 30 to 40 percent of the time to say, 'Hey, guess what, we have to do this again.' I just think that's too high," said Dr. Laurence McCahill, from the Lacks Cancer Center at Saint Mary's Health Care in Grand Rapids, Michigan, who worked on the study.

"For many reasons, (a second surgery) is very hard on patients," he told Reuters Health. "It's hard on patients from a psychological standpoint, from a physical standpoint and from an economical standpoint as well."

Breast-conserving surgery, also called partial mastectomy or lumpectomy, on average costs between $6,000 and $7,000, according to the Healthcare Blue Book.

McCahill's team studied about 2,200 women getting a first breast-conserving surgery at four different research sites in the United States between 2003 and 2008.

In that procedure -- a typical initial breast cancer treatment along with radiation -- the surgeon tries to remove just the cancerous cells and a few healthy ones around them to keep the breast as intact as possible.

But in 23 percent of the study cases, surgeons decided from lab reports that they didn't take out enough cells in the first operation, and went back in to remove more tissue. Between eight and nine percent of all women initially getting breast-conserving surgery ended up later having a total mastectomy.

McCahill and his colleagues didn't know what went into each surgeon's decision to do a second surgery on a particular woman, and they couldn't tell whether those re-operations, or re-excisions, reduced the risk of the cancer coming back.

But they did find that the rate of re-operations varied greatly between doctors. Individual surgeons performed a second procedure on anywhere from none to 70 percent of their patients, the researchers reported Tuesday in the Journal of the American Medical Association.

"We were as concerned with the zero percent re-excision rate," McCahill said, as that might mean doctors were removing too much tissue on the first surgery or weren't operating again when they left cancer cells behind.

That's why it probably wouldn't be a good idea to measure or reward surgeons based on how low their rates of re-operation are, he said. Instead, McCahill suggested doctors working together and with their patients to get that rate down to somewhere between one out of every twenty and one out of every five women needing re-excision.

Dr. Monica Morrow, who co-wrote a commentary published with the study, said it isn't possible for surgeons to avoid all situations that might require a re-operation, since some cancer cells are too difficult to spot or feel on a first surgery.

"What patients need to be aware of is that if you have a lumpectomy, it is possible you might need to have a re-excision. But in the scheme of things, this is a small, low-risk operation," she told Reuters Health

"Saying to your surgeon, 'What's your re-excision rate?' is not a way to measure the quality of the surgery you're going to get," added Morrow, from Memorial Sloan-Kettering Cancer Center in New York.

Dr. Alphonse Taghian, head of breast radiation oncology at Massachusetts General Hospital Cancer Center in Boston, agreed.

"I do not think that this should be a measure of the quality of treatment," said Taghian, who wasn't involved in the new study.

"Some surgeons will make a very big excision from the first time, so you gain in terms of not having a re-excision, but you might lose in terms of cosmetic results," he told Reuters Health.

McCahill said that it's important for women getting breast-conserving surgery to talk with their doctors about where their priorities lie, and how willing they are to have to go under the knife a second time.

"There are definitely women who will say, 'Just go tight (around the cancer cells), and if we have to do this again, I'm okay with that,'" he said. Other women will say, "'Hey, take a little more, I'm okay with my body image.'"

SOURCE: http://bit.ly/hwxtTL Journal of the American Medical Association, online January 31, 2012.

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