Influence of the SSO/ASTRO Margin Reexcision Guidelines on Costs Associated with Breast-Conserving Surgery.

BACKGROUND: The reported reexcision rates vary significantly for patients with invasive breast cancer undergoing breast-conserving surgery (BCS). This variability is a function of both the positive pathologic margin rate and the interpretation of an adequate pathologic margin. The influence of the SSO/ASTRO margin guidelines on reexcision rates and the potential cost savings is of interest from both quality and health economics perspectives. METHODS: A retrospective analysis of all patients undergoing BCS during a 3-year period (January 1, 2010-December 31, 2012) was performed. The reexcision rate and the pathologic margin status were assessed to determine the number of patients with pathologic negative margins who underwent reexcision. A decision analysis using previously published case costing information was used to determine the potential savings associated with avoidance of reoperation for patients meeting guidelines criteria. RESULTS: The analysis included 512 patients who underwent attempted BCS for invasive breast cancer. Reoperations occurred for 25% (126/512) of the BCS cohort, but this rate could potentially be decreased to 16% (44/512) if these guidelines were applied. Based on our cost model, application of the guidelines would provide a potential cost savings of $698 (95% confidence interval $523-$893) per patient undergoing attempted BCS in our population. CONCLUSIONS: Adherence to the SSO-ASTRO guidelines could prevent one-third of reoperations among patients undergoing BCS. This would result in significant cost savings to the health care system while avoiding unnecessary operations. Use of guidelines has the potential to improve the quality of care provided to patients.

Reoperation costs in attempted breast-conserving surgery: a decision analysis.

BACKGROUND: Breast-conserving surgery (bcs) is the preferred surgical approach for most patients with early-stage breast cancer. Frequently, concerns arise about the pathologic margin status, resulting in an average reoperation rate of 23% in Canada. No consensus has been reached about the ideal reoperation rate, although 10% has been suggested as a target. Upon undergoing reoperation, many patients choose mastectomy and breast reconstruction, which add to the morbidity and cost of patient care. We attempted to identify the cost of reoperation after bcs, and the effect that a reduction in the reoperation rate could have on the B.C. health care system. METHODS: A decision tree was constructed to estimate the average cost per patient undergoing initial bcs with two reoperation frequency scenarios: 23% and 10%. The model included the direct medical costs from the perspective of the B.C. health care system for the most common surgical treatment options, including breast reconstruction and postoperative radiation therapy. RESULTS: Costs ranged from a low of $8,225 per patient with definitive bcs [95% confidence interval (ci): $8,061 to $8,383] to a high of $26,026 for reoperation with mastectomy and delayed reconstruction (95% ci: $23,991 to $28,122). If the reoperation rate could be reduced to 10%, the average saving would be $1,055 per patient undergoing attempted bcs (95% ci: $959 to $1,156). If the lower rate were to be achieved in British Columbia, it would translate into a savings of $1.9 million annually. SUMMARY: The implementation of initiatives to reduce reoperation after bcs could result in significant savings to the health care system, while potentially improving the quality of patient care.

Surgeon Volume, Patient Age, and Tumor-Related Factors Influence the Need for Re-Excision After Breast-Conserving Surgery.

BACKGROUND: Breast-conserving surgery (BCS) is the preferred surgical approach for the majority of patients with early-stage breast cancer. There are frequent issues regarding pathologic margin status, requiring margin re-excision, and, in the literature, there is significant variability in re-excision rates, suggesting this is a potential quality-of-care issue. Understanding the patient-, disease-, and physician-related factors influencing reoperation rates is of importance in an effort to minimize this occurrence. METHODS: A retrospective analysis of all patients referred to our cancer center over a 3-year period (1 January 2011-31 December 2013) was performed. Surgeon volume, and patient- and tumor-related factors were assessed for their impact on re-excision rates. Multivariate logistic regression analysis was performed to identify variables of significance influencing reoperation rates after attempted BCS. RESULTS: Overall, 594 patients underwent initial BCS, with 159 (26.8%) patients requiring at least one re-excision to ensure negative pathologic margins. On multivariate analysis, low surgeon case volume, patient age (under 46 years of age), tumor size (>2 cm), and lobular carcinoma were associated with an increased re-excision rate. CONCLUSION: Re-excisions are frequent after BCS and are influenced by surgeon volume, patient age, and tumor-related factors. These factors should be considered when counseling patients considering BCS, and also for quality assurance.

Population-based analysis of the impact and generalizability of the NSABP-B24 study on endocrine therapy for patients with ductal carcinoma in situ of the breast.

BACKGROUND: In 1999, the National Surgical Adjuvant Breast and Bowel Project (NSABP)-B24 trial demonstrated that tamoxifen reduced relapse risk in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) and radiotherapy (RT). In 2002, Allred's subgroup analysis showed that tamoxifen mainly benefitted estrogen receptor (ER)-positive disease. This study evaluates the impact and generalizability of these trial findings at the population level. PATIENTS AND METHODS: From 1989 to 2009, 2061 women with DCIS underwent BCS + RT in British Columbia. The following cohorts were analyzed: (1) pre-NSABP-B24 era (1989-1998, N = 417); (2) post-NSABP-B24 era (2000-2009, N = 1548). Cohort 2 was further divided into pre- and post-Allred eras. RESULTS: Endocrine therapy (ET) was used in 404/2061 (20%) patients. Median age of patients treated with compared with without ET, was 53 versus 57 years, (P < 0.0005). One of 417 (0.2%) versus 399/1548 (26%) patients took ET before versus after NSABP-B24. Among the post-Allred era cohort treated with ET (N = 227), tumors were ER-positive in 65%, ER-negative in 1%, and ER-unknown in 33%; whereas of those treated without ET (N = 801), ER was positive in 43%, negative in 15%, and unknown in 42% (P < 0.0005). On multivariable analysis of the post-NSABP-B24 era, ET was associated with improved event-free survival (EFS) (hazard ratio 0.6; P = 0.02); 5-year EFS were 96.9% with ET versus 94.5% without ET. CONCLUSIONS: ET use in DCIS patients treated with BCS + RT increased significantly after the NSABP-B24 study. ER+ disease and younger age were associated with increased ET use. ET was associated with improved EFS, confirming the generalizability of trial data at a population level.

Hemithyroidectomy: the preferred initial surgical approach for management of Hurthle cell neoplasm.

BACKGROUND: The objective of this study was to evaluate the cancer risk of patient clinicopathologic characteristics to determine the optimal approach for the surgical management of individuals with Hurthle cell neoplasm (HN) diagnosed by cytology. METHODS: Patient clinicopathologic characteristics evaluated included age, sex, tumor size, and ipsilateral thyroid lobe nodularity. The association of these characteristics with a pathologic cancer diagnosis was evaluated using Fisher's exact test and Student t test. RESULTS: Of the 422 patients undergoing thyroidectomy, 27 presented with a fine-needle aspiration biopsy diagnosis of HN, and by pathologic assessment 7 HN patients (25.9%) had a cancer diagnosis. Although none of the clinicopathologic characteristics evaluated were able to reliably differentiate benign from malignant tumors, large tumor size and male sex were significantly associated with a pathologic diagnosis of Hurthle cell carcinoma (P < .05). CONCLUSIONS: Hemithyroidectomy represents the preferred initial surgical approach for the management of individuals presenting with nodular thyroid disease and a cytologic diagnosis of HN.