Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members
Factors Associated with Reoperation in Breast-Conserving Surgery for Cancer: A Prospective Study of American Society of Breast Surgeon Members
复制标题
DOI：
10.1245/s10434-019-07547-w
复制
发表时间：
2019-10-01
影响因子：
3.7
通讯作者：
Wilke, Lee
中科院分区：
文献类型：
--
作者：
Landercasper, Jeffrey;Borgert, Andrew J.;Wilke, Lee
背景：超过20%的癌症患者接受首次保乳手术（BCS）需要再次手术。为了解决这一问题，美国乳房外科医生协会（ASBrS）在2015年批准了10项护理流程（工具），供外科医生考虑，以减少再手术的发生。在计划的随访中，我们试图确定哪些工具与较少的再手术相关。方法一组ASBrS成员外科医生前瞻性地将2017年连续接受BCS患者的数据输入ASBrS Mastery (R)注册表。通过多变量和分层排序分析来估计工具和再操作之间的关联。结果3954例患者中，486例（12.3%）有71名外科医生报告再手术，平均12.7%[标准差（SD） 7.7%]，中位数11.5%[范围0-32%]。第10百分位组和第90百分位组的外科医生之间有8倍的差异。与减少再手术相关的可操作因素包括常规计划的腔侧壁刮刀，外科医生使用超声（US），新辅助化疗，术中病理边缘评估，以及使用传统二维乳房x线摄影之外的术前诊断成像方式。对于侵袭性癌症患者，>= 24%的患者在报告的切缘< 1或2mm时进行了再切除，这表明不符合SSO-ASTRO切缘指南。结论：尽管ASBrS成员外科医生的再手术率在所有登记中都是最低的，但显著的外科医生间差异仍然存在。因此，有必要进一步努力降低利率。通过采用这些护理流程确定了这样做的机会，包括改进对SSO-ASTRO裕度指南的遵守，这与减少再手术有关。
Background More than 20% of patients undergoing initial breast-conserving surgery (BCS) for cancer require reoperation. To address this concern, the American Society of Breast Surgeons (ASBrS) endorsed 10 processes of care (tools) in 2015 to be considered by surgeons to de-escalate reoperations. In a planned follow-up, we sought to determine which tools were associated with fewer reoperations. Methods A cohort of ASBrS member surgeons prospectively entered data into the ASBrS Mastery (R)' registry on consecutive patients undergoing BCS in 2017. The association between tools and reoperations was estimated via multivariate and hierarchical ranking analyses. Results Seventy-one surgeons reported reoperations in 486 (12.3%) of 3954 cases (mean 12.7% [standard deviation (SD) 7.7%], median 11.5% [range 0-32%]). There was an eightfold difference between surgeons in the 10th and 90th percentile performance groups. Actionable factors associated with fewer reoperations included routine planned cavity side-wall shaves, surgeon use of ultrasound (US), neoadjuvant chemotherapy, intra-operative pathologic margin assessment, and use of a pre-operative diagnostic imaging modality beyond conventional 2D mammography. For patients with invasive cancer, >= 24% of those who underwent reexcision did so for reported margins of < 1 or 2 mm, representing noncompliance with the SSO-ASTRO margin guideline. Conclusions Although ASBrS member surgeons had some of the lowest rates of reoperation reported in any registry, significant intersurgeon variability persisted. Further efforts to lower rates are therefore warranted. Opportunities to do so were identified by adopting those processes of care, including improved compliance with the SSO-ASTRO margin guideline, which were associated with fewer reoperations.