Repeat surgery common after lumpectomy, especially for young women

Nearly 1 in 4 women who have lumpectomy, also called breast conservation surgery, has additional surgery within 90 days, a recent study in JAMA Surgery shows. Women younger than age 50 have the highest rates of reoperation, or added surgery.

The study also showed that reoperation rates varied with how often a surgeon performed lumpectomies. Surgeons who performed the fewest in a given year had the highest number of repeat surgeries.

Background

Lumpectomy and mastectomy are surgical treatments for early-stage breast cancer. In mastectomy, the surgeon removes the entire breast. In lumpectomy, the surgeon removes only the tumor and a rim of healthy surrounding tissue called the margin. This is often followed by radiation therapy.

After lumpectomy, tests might show breast cancer cells are still in the margin area. When that happens, another surgery is needed to remove those cells. There also may be added surgery to make the margin area that is clear of cancer wider. The best width for this area has been much debated. Reoperation can be either another lumpectomy, or mastectomy.

Studies have shown that survival rates are about the same for people who have lumpectomy and people who have mastectomy. But lumpectomy has a slightly higher risk of local recurrence, cancer that returns to the area where it was first diagnosed. In the past 10 years, young women chose mastectomy instead of lumpectomy more often than in previous years.

In this study, researchers wanted to learn how often lumpectomy was used as the first surgery for women with breast cancer in New York state and what factors might contribute to needing additional surgery. They also were looking to see what about the doctors or the women getting surgery may have influenced how often another surgery was needed.

Design

The study looked at records for 89,448 women with early-stage breast cancer who had lumpectomy as their first breast cancer surgery from January 2003 through December 2013. The women were all from New York state. Most were white and half had private insurance.

Researchers looked at medical records to find how often a repeat lumpectomy or mastectomy was needed within 90 days of a woman’s first surgery, and to see if a third lumpectomy occurred within 90 days of the second.

They also gathered information on the women’s surgeons and how many lumpectomies each performed in a year.

Results

The use of lumpectomy as the first surgery fell during the study period in women under 50. It dropped from 1,960 women in 2003, about 24 percent of women who had lumpectomy that year, to 1,416 in 2013, or 17.4 percent of the year’s total. Use of lumpectomy varied only slightly for older women in that same time period.

The rate of additional surgery in the 90 days after lumpectomy fell over time for all women:

• 39.5 percent in 2003 to 2004
• 23.1 percent in 2011 to 2013

During the study period, nearly 31 percent of women who had lumpectomy needed another surgery to remove the cancer. A higher percentage of young women – almost 38 percent – needed more surgery. Women with DCIS were also more likely to have additional surgery.

Surgeons who performed:

• fewer than 14 lumpectomies per year had a 35.2 percent reoperation rate
• 14 to 33 lumpectomies per year had a 29.6 percent reoperation rate
• 34 or more lumpectomies per year had a 27.5 percent reoperation rate

Limitations

Data were not adjusted based on tumor size, grade or staging because that information was not available to the researchers. These factors could influence the need for more surgery. The study also did not measure if cancer returned or whether the women were satisfied with how their breasts looked after surgery.

Changing surgical standards

This study looked at additional surgeries that happened before new margin guidelines were published by the Society of Surgical Oncology and American Society of Radiation Oncology in 2014.

In the new guidelines, the margin is clear, or free of cancer, if there are no cancer cells found in the marked outer edge of the removed tissue. Earlier standards asked for more healthy tissue between the edge and any cancer cells. The guidelines committee looked at other studies and found that additional surgery to make clear margins wider in early-stage breast cancer did not significantly lower the risk of cancer returning as long as radiation therapy was also used. These studies did not include ductal carcinoma in situ, or stage 0 breast cancer, which is not invasive.

What this means for you

When deciding about surgery for early-stage breast cancer, it helps to talk with your healthcare team about the differences between lumpectomy and mastectomy. Lumpectomy lets women keep more of their breast and have a shorter recovery.

Many women who have lumpectomy do not need additional surgery. This study shows that 1 in 4 women who have lumpectomy need added surgery because their surgical margins are not clear, or the clear margin is not wide enough. Recent guidelines for a narrower margin are likely to lower reoperation rates.

You should also consider your surgeon when making a decision about treatment. Ask the breast surgeon how many lumpectomies she or he performs. As this study shows, having a surgeon who conducts more lumpectomies in a year improves your chances of not needing additional surgery. If you are limited in your choice of surgeon by insurance or where you live, choose someone who is experienced in performing lumpectomies and who talks with you fully about the surgery and your concerns. Talk with another surgeon if you feel uncertain about the first one you see. Such second opinions are OK and help you find the care you need.

It may help you feel more confident to bring a list of questions with you and have a supportive friend or loved one there. If you are uncertain, get a second opinion from another surgeon. Our Breast Cancer Helpline is here to support you as you make the decision that’s best for you.

Isaacs, AJ, Gemignani, ML, Pusic, A, Sedrakyan, A. Association of Breast Conservation Surgery for Cancer With 90-Day Reoperation Rates in New York State. JAMA Surgery 2016; doi: 10.1001/jamasurg.2015.5535