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Original Contribution
February 1, 2012

Variability in Reexcision Following Breast Conservation Surgery

Author Affiliations

Author Affiliations: Richard J. Lacks Cancer Center, Van Andel Research Institute, and Department of Surgery, Michigan State University, Grand Rapids (Dr McCahill); Departments of Mathematics and Statistics (Dr Single) and Surgery (Dr James), University of Vermont, Burlington; Group Health Research Institute, Seattle, Washington (Ms Aiello Bowles); Kaiser Permanente Colorado, Denver (Dr Feigelson); Van Andel Research Institute, Grand Rapids, Michigan (Mr Barney); Marshfield Clinic Cancer Care at St Michaels, Stevens Point, and Marshfield Clinic Research Foundation, Marshfield, Wisconsin (Ms Engel); and Marshfield Clinic Hematology/Oncology Department, Weston Center, Weston, and Marshfield Clinic Research Foundation, Marshfield, Wisconsin (Dr Onitilo).

JAMA. 2012;307(5):467-475. doi:10.1001/jama.2012.43

Context Health care reform calls for increasing physician accountability and transparency of outcomes. Partial mastectomy is the most commonly performed procedure for invasive breast cancer and often requires reexcision. Variability in reexcision might be reflective of the quality of care.

Objective To assess hospital and surgeon-specific variation in reexcision rates following partial mastectomy.

Design, Setting, and Patients An observational study of breast surgery performed between 2003 and 2008 intended to evaluate variability in breast cancer surgical care outcomes and evaluate potential quality measures of breast cancer surgery. Women with invasive breast cancer undergoing partial mastectomy from 4 institutions were studied (1 university hospital [University of Vermont] and 3 large health plans [Kaiser Permanente Colorado, Group Health, and Marshfield Clinic]). Data were obtained from electronic medical records and chart abstraction of surgical, pathology, radiology, and outpatient records, including detailed surgical margin status. Logistic regression including surgeon-level random effects was used to identify predictors of reexcision.

Main Outcome Measure Incidence of reexcision.

Results A total of 2206 women with 2220 invasive breast cancers underwent partial mastectomy and 509 patients (22.9%; 95% CI, 21.2%-24.7%) underwent reexcision (454 patients [89.2%; 95% CI, 86.5%-91.9%] had 1 reexcision, 48 [9.4%; 95% CI, 6.9%-12.0%] had 2 reexcisions, and 7 [1.4%; 95% CI, 0.4%-2.4%] had 3 reexcisions). Among all patients undergoing initial partial mastectomy, total mastectomy was performed in 190 patients (8.5%; 95% CI, 7.2%-9.5%). Reexcision rates for margin status following initial surgery were 85.9% (95% CI, 82.0%-89.8%) for initial positive margins, 47.9% (95% CI, 42.0%-53.9%) for less than 1.0 mm margins, 20.2% (95% CI, 15.3%-25.0%) for 1.0 to 1.9 mm margins, and 6.3% (95% CI, 3.2%-9.3%) for 2.0 to 2.9 mm margins. For patients with negative margins, reexcision rates varied widely among surgeons (range, 0%-70%; P = .003) and institutions (range, 1.7%-20.9%; P < .001). Reexcision rates were not associated with surgeon procedure volume after adjusting for case mix (P = .92).

Conclusion Substantial surgeon and institutional variation were observed in reexcision following partial mastectomy in women with invasive breast cancer.