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Original Investigation
August 26, 2020

Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery: A Systematic Review and Meta-analysis

Author Affiliations
  • 1School of Public Health, Curtin University, Bentley, Western Australia, Australia
  • 2Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  • 3Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
JAMA Surg. 2020;155(10):e203025. doi:10.1001/jamasurg.2020.3025
Key Points

Question  Was the publication of the Society of Surgical Oncology–American Society for Radiation Oncology (SSO-ASTRO) margins guideline associated with a change in reoperation rates?

Findings  In this systematic review and meta-analysis of 30 studies involving 599 016 participants, the odds of reoperation after a breast-conserving surgical procedure were statistically significantly lower after publication of the SSO-ASTRO guideline. Decreases in reoperation were greater at the institutional level than at the population level and when a larger negative margin was used in the preguideline period.

Meaning  This study suggests that the SSO-ASTRO guideline is associated with a significant reduction in reoperation rates, an outcome that may improve with further adoption of SSO-ASTRO guideline recommendations.


Importance  The 2014 publication of the Society of Surgical Oncology–American Society for Radiation Oncology (SSO-ASTRO) Consensus Guideline on Margins for Breast-Conserving Surgery recommended a negative margin definition of no ink on tumor. Adoption of this guideline would represent a major change in surgical practice that could lower the rates of reoperation.

Objective  To assess changes in reoperation rates after publication of the SSO-ASTRO guideline.

Data Sources  A systematic search of Embase, PREMEDLINE, Evidence-Based Medicine Reviews, Scopus, and Web of Science for biomedical literature published from January 2014 to July 2019 was performed. This search was supplemented by web searches and manual searching of conference abstracts.

Study Selection  Included studies compared the reoperation rates in preguideline vs postguideline cohorts (actual change), retrospectively applied the SSO-ASTRO guideline to a preguideline cohort (projected change), or described the economic outcomes of the guideline.

Data Extraction and Synthesis  Study characteristics and reoperation rates were extracted independently by 2 reviewers. Odds ratios (ORs) were pooled by random effects meta-analysis. Analyses were stratified by study setting (institutional or population) and preguideline accepted margins. The economic outcomes of the guideline were summarized narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed.

Main Outcomes and Measures  Odds ratios for postguideline vs preguideline reoperation rates.

Results  From 1114 citations, 30 studies (with 599 016 participants) reported changes in reoperation rates. Studies included a median (range) of 487 (100-521 578) participants, and 20 studies were undertaken in the US, 6 in the UK, 3 in Canada, and 1 in Australia. Among 21 studies of actual changes, pooled ORs showed a statistically significant reduction in reoperation, with an OR lower in institution-based studies than in population-based studies (OR, 0.62 [95% CI, 0.52-0.74] vs 0.76 [95% CI, 0.72-0.80]; P = .04 for subgroup differences). Among 9 studies of projected changes, the pooled OR was lower for preguideline margin thresholds of 2 mm or more compared with 1 mm (OR, 0.47 [95% CI, 0.40-0.56] vs 0.85 [95% CI, 0.79-0.91; P < .001 for subgroup differences). Projected changes were likely to overestimate actual changes. Six studies that estimated the postguideline economic outcome found the guideline to be potentially cost saving, with a median (range) saving of US $3540 ($1800-$25 650) per woman avoiding reoperation.

Conclusions and Relevance  This study found a decrease in reoperation rates after the publication of the SSO-ASTRO guideline; this reduction was greater at an institutional level than a population level, the latter reflecting the differences in guideline adoption between centers. These early outcomes may be conservative estimates of longer-term implications.

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