Trends in Reoperation After Initial Lumpectomy for Breast Cancer Addressing Overtreatment in Surgical Management
Trends in Reoperation After Initial Lumpectomy for Breast Cancer Addressing Overtreatment in Surgical Management
复制标题
DOI：
10.1001/jamaoncol.2017.0774
复制
发表时间：
2017-10-01
期刊：
影响因子：
28.4
通讯作者：
Jagsi, Reshma
中科院分区：
文献类型：
--
作者：
Morrow, Monica;Abrahamse, Paul;Jagsi, Reshma
重要性初次乳房肿瘤切除术后进行手术以获得更广泛清晰的边缘是常见的，可能导致乳房切除术。目的描述外科医生对浸润性乳腺癌手术边缘的方法，以及乳房肿瘤切除术后手术率的变化，以及2014年共识声明支持“肿瘤无墨水”边缘后的最终手术治疗。设计、设置和参与者这是一项基于人群的队列调查研究，纳入了7303名符合条件的女性，年龄在20至79岁之间，在2013年至2015年诊断为I期和II期乳腺癌，并从格鲁吉亚和洛杉矶县、加州、监测、流行病学和最终结果登记处确定。共有5080人（70%）返回了调查。排除了双侧病变、缺失分期或治疗数据以及导管原位癌的患者，分析样本中留下3729例患者;其中98%确定了他们的主治医生。在2015年4月至2016年5月期间，对488名外科医生进行了关于乳房肿瘤切除术边缘的调查; 342名（70%）完全回答。对所有接受第二次手术的患者和30%接受1次手术的患者的病理报告进行了审查。时间趋势进行了分析与多项式回归models.Main结局和措施率的最终手术程序（乳房肿瘤切除术，单侧乳房切除术，双侧乳房切除术）和率的额外手术后，初步乳房肿瘤切除术随着时间的推移，和外科医生的态度，以充分的乳房肿瘤切除术margin.Results的67%率的初步乳房肿瘤切除术在3729例分析样本在研究过程中没有变化。2013年至2015年，最终乳房肿瘤切除率增加了13%，同时单侧和双侧乳房切除率下降（P = .002）。初次乳房肿瘤切除术后的手术率下降了16%（P <0.001）。病理学审查记录治疗日期与阳性切缘之间无显著相关性。在342名回应的外科医生中，69%的人赞同肿瘤上没有墨水的边缘，以避免雌激素受体阳性孕激素受体阳性癌症的再次切除，63%的人赞同雌激素受体阴性孕酮受体阴性癌症的再次切除。每年治疗超过50例乳腺癌的外科医生更有可能报告这一差距是足够的（85%; n = 105）与治疗20例或更少病例相比（占55%; n = 131）（P <0.001）结论和相关性随着临床指南的传播，2013年至2015年初次乳房肿瘤切除术后的额外手术显著减少。支持最小的负边际。这些发现表明，外科医生主导的解决潜在过度治疗的举措可以减轻癌症患者的手术管理负担。
IMPORTANCE Surgery after initial lumpectomy to obtain more widely clear margins is common and may lead to mastectomy.OBJECTIVE To describe surgeons' approach to surgical margins for invasive breast cancer, and changes in postlumpectomy surgery rates, and final surgical treatment following a 2014 consensus statement endorsing a margin of "no ink on tumor."DESIGN, SETTING, AND PARTICIPANTS This was a population-based cohort survey study of 7303 eligible women ages 20 to 79 years with stage I and II breast cancer diagnosed in 2013 to 2015 and identified from the Georgia and Los Angeles County, California, Surveillance, Epidemiology, and End Results registries. A total of 5080 (70%) returned a survey. Those with bilateral disease, missing stage or treatment data, and with ductal carcinoma in situ were excluded, leaving 3729 patients in the analytic sample; 98% of these identified their attending surgeon. Between April 2015 and May 2016, 488 surgeons were surveyed regarding lumpectomy margins; 342 (70%) responded completely. Pathology reports of all patients having a second surgery and a 30% sample of those with 1 surgery were reviewed. Time trends were analyzed with multinomial regression models.MAIN OUTCOMES AND MEASURES Rates of final surgical procedure (lumpectomy, unilateral mastectomy, bilateral mastectomy) and rates of additional surgery after initial lumpectomy over time, and surgeon attitudes toward an adequate lumpectomy margin.RESULTS The 67% rate of initial lumpectomy in the 3729 patient analytic sample was unchanged during the study. The rate of final lumpectomy increased by 13% from 2013 to 2015, accompanied by a decrease in unilateral and bilateral mastectomy (P = .002). Surgery after initial lumpectomy declined by 16%(P < .001). Pathology review documented no significant association between date of treatment and positive margins. Of 342 responding surgeons, 69% endorsed a margin of no ink on tumor to avoid reexcision in estrogen receptor-positive progesterone receptor-positive cancer and 63% for estrogen receptor-negative progesterone-receptor-negative cancer. Surgeons treating more than 50 breast cancers annually were significantly more likely to report this margin as adequate (85%; n = 105) compared with those treating 20 cases or fewer (55%; n = 131) (P < .001).CONCLUSIONS AND RELEVANCE Additional surgery after initial lumpectomy decreased markedly from 2013 to 2015 concomitant with dissemination of clinical guidelines endorsing a minimal negative margin. These findings suggest that surgeon-led initiatives to address potential overtreatment can reduce the burden of surgical management in patients with cancer.