Breast-conserving surgery carries high reoperation risk

By Piriya Mahendra

Women who undergo breast-conserving surgery for breast cancer may be at an increased risk for reoperation, research suggests.

One in five women with breast cancer who underwent breast-conserving surgery in England between 2005 and 2008 had a reoperation, say David Cromwell (London School of Hygiene and Tropical Medicine, UK) and team in the BMJ.

It is therefore important that clinicians inform women of this reoperation risk when deciding on the best type of surgical treatment for their breast cancer, they stress.

In particular, the team found that reoperation was significantly more common among women with a carcinoma in situ component recorded at the time of the primary breast-conserving surgery than in those without, at 29.5% versus 18.0%.

The increased risk for reoperation among women with a carcinoma in situ component coded persisted after adjustment for age, comorbidities, and socioeconomic factors, at an odds ratio of 1.9 compared with those who did not have a carcinoma in situ component.

"The problem partly relates to difficulties in identifying the extent rather than just the presence of carcinoma in situ, because many tumors are multifocal," the authors explain.

"Greater use of imaging techniques, such as whole breast ultrasonography, may help to reduce this problem."

Of the 55,297 women who had primary breast-conserving surgery in the UK from 2005 to 2008, 11,032 (20.0%) had at least one reoperation within 3 months.

Of these, 10,212 (18.5%) had one reoperation only - 5943 (10.7%) had a further breast-conserving procedure and 4269 (7.7%) had a mastectomy. The remaining 820 (1.5%) women had two or more reoperations.

This means that of the 5943 women who had a second breast-conserving procedure, 13.8% had inadequate margins and needed at least one more reoperation, the authors note.

Among women who had just one reoperation, the proportion who had mastectomy rather than another breast-conserving procedure was not significantly associated with whether or not their tumor had a carcinoma in situ component coded.

Further analysis revealed that the reoperation rate among women who had breast-conserving surgery varied significantly across the 148 UK National Health Service (NHS) trusts included in the study.

After adjusting for patients' characteristics, "some English NHS trusts had adjusted reoperation rates below 10%, whereas for others it was above 30%," the authors note.

"This raises questions about the uniformity of the selection criteria for both primary breast-conserving surgery and reoperation," they say.

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