Study Shows Many Women Need Repeat Surgery After Lumpectomy
A recent study examined the average number of repeat surgeries needed for women undergoing lumpectomy, also called breast conservation surgery. The study found that approximately one-fourth of women who have breast conservation surgery go on to have some type of repeat breast surgery – whether an additional lumpectomy or complete mastectomy. The rate of repeat surgeries varied greatly by the person, the tumor and the treatment facility. However, repeat surgeries were most common in the Northeast as compared to the Mountain region, and more common at academic or research hospitals than at community hospitals.
The study attributed the varied rate of repeat surgeries to the lack of a universally agreed-upon amount of tissue around a tumor that should be removed during breast conservation, called a margin. When a person has clear margins after surgery, no cancer cells are seen in the tissue left around the area where the tumor was found. The study authors concluded that establishing clear margin guidelines could help surgeons lower the need for repeat surgeries.
Background and Goals
Many women have additional surgeries after breast conserving surgery because cancer cells are found in the tissues near the edge of the area removed, called the margin. The researchers on this study wanted to find out how common repeat surgeries are, and use the findings to help surgeons and women make treatment decisions or find ways to avoid the extra surgeries. “Repeat surgeries take a financial, emotional and physical toll on patients,’’ says lead author Lee G. Wilke, MD, FACS, director of the UW Health Breast Center at the UW Carbone Cancer Center. “All surgeons and their institutional team members should know their own rate of repeat surgeries and work to identify processes to reduce this rate of second surgery.”
In this study, researchers identified 316,114 women aged 18 and up who had been diagnosed with stage 0 to II breast cancer and had initial breast conservation surgery using the National Cancer Data Base. None had been treated with neoadjuvant, or pre-surgical, medical therapy, and none were diagnosed by excisional biopsy, meaning they did not have surgery to diagnose the cancer. Of the women,
- 76.4 percent had a single lumpectomy
- 23.6 percent had at least one additional surgery
- the majority of this 23.6 percent had completion lumpectomy, a second and separate lumpectomy surgery to achieve clear margins
Factors such as age, race, health insurance status and having other medical conditions impacted the need for additional surgery. The majority of those who had repeat surgery were white, aged 50-59, had managed healthcare, no additional medical conditions, and estrogen receptor-positive breast cancer.
In addition, these factors were associated with more surgery:
- Tumor size. Women with tumors between 2 and 5 cm were 23 percent more likely to need repeat surgeries than women with tumors smaller than 2 cm.
- Type of breast cancer. Women with ductal carcinoma in situ or infiltrating lobular cancer were more likely to have additional surgeries, than those with infiltrating ductal cancer.
- Cancer cells in the lymph nodes. 26.2 percent of women with cancer cells found in the lymph nodes had repeat surgery, compared to 17 percent of those with no cancer cells in the lymph nodes.
- Women who had mastectomy as a final surgery had a higher percentage of invasive lobular carcinoma and had larger tumors
In this observation study, the authors found a wide range of rates of repeat surgery across the country. These rates varied and were related to tumor, patient and facility factors. “Past studies were too small and too regional to know the true national statistics,’’ says Wilke. “Now we have a baseline, and while it declined slightly during the study period (from 25.4 to 23.7 percent) it is still too high. We’ll never get to zero but 10 percent is a reasonable goal.”
This study drew data from multiple hospitals and cancer centers using the National Cancer Data Base, a large database of accredited cancer centers. The database did not examine the number of reexcisions, or reopening of the lumpectomy site to remove more tissue. It only collected information on the number of additional surgeries performed separately from the first breast conserving surgery. It also did not have any data on recurrence rates, and therefore the authors could not correlate repeat surgery rates with local tumor recurrences.
What This Means For You
This study shows that many factors impact whether or not you need additional surgeries after lumpectomy. The tumor size, hormone receptor-status of the disease and whether the cancer traveled to your lymph nodes may all play a part. These factors, plus no standard margin width in practice across the country, means that surgeons may not be able to predict who will need more surgeries when making treatment plans. The adoption of national standards of adequate margins recently proposed by the Society of Surgical Oncology and the American Society of Radiation Oncology may result in a decrease this wide variation in the future.
An open conversation with your surgeon about your individual experience may help ease any anxiety you feel. Because repeat surgeries may increase costs and add more to your healing time, it’s important to understand your options and the resources available to you.
Lee G. Wilke, MD; Tomasz Czechura, MPH; ChihWang, PhD; Brittany Lapin, MPH; Erik Liederbach, BS; David P. Winchester, MD; Katharine Yao, MD Repeat Surgery After Breast Conservation for the Treatment of Stage 0 to II Breast Carcinoma. JAMA Surg. (2014); doi:10.1001/jamasurg.2014.926.