Tomasz Czechura

Repeat Surgery After Breast Conservation for the Treatment of Stage 0 to II Breast Carcinoma A Report From the National Cancer Data Base, 2004-2010

IMPORTANCE Although complete excision of breast cancer is accepted as the best means to reduce local recurrence and thereby improve survival, there is currently no standard margin width for breast conservation surgery. As a result, significant variability exists in the number of additional operations or repeat surgeries patients undergo to establish tumor-negative margins. OBJECTIVE To determine the patient, tumor, and facility factors that influence repeat surgery rates in US patients undergoing breast conservation surgery. DESIGN, SETTING, AND PATIENTS Patients diagnosed as having breast cancer at a Commission on Cancer accredited center from January 1, 2004, through December 31, 2010, and identified via the National Cancer Data Base, a large observational database, were included in the analysis. A total of 316,114 patients with stage 0 to II breast cancer who underwent initial breast conservation surgery were studied. Patients who were neoadjuvantly treated or whose conditions were diagnosed by excisional biopsy were excluded. MAIN OUTCOMES AND MEASURES Patient, tumor, and facility factors associated with repeat surgeries. RESULTS A total of 241,597 patients (76.4%) underwent a single lumpectomy, whereas 74,517 (23.6%) underwent at least 1 additional operation, of whom 46,250 (62.1%) underwent a completion lumpectomy and 28,267 (37.9%) underwent a mastectomy. The proportion of patients undergoing repeat surgery decreased slightly during the study period from 25.4% to 22.7% (P < .001). Independent predictors of repeat surgeries were age, race, insurance status, comorbidities, histologic subtype, estrogen receptor status, pathologic tumor size, node status, tumor grade, facility type and location, and volume of breast cancer cases. Age was inversely associated with repeat surgery, decreasing from 38.5% in patients 18 to 29 years old to 16.5% in those older than 80 years (P < .001). In contrast, larger tumor size was linearly associated with a higher repeat surgery rate (P < .001). Repeat surgeries were most common at facilities located in the Northeast region (26.5%) compared with facilities in the Mountain region, where only 18.4% of patients underwent repeat surgery (P < .001). Academic or research facilities had a 26.0% repeat surgery rate compared with a rate of 22.4% at community facilities (P < .001). CONCLUSIONS AND RELEVANCE Approximately one-fourth of all patients who undergo initial breast conservation surgery for breast cancer will have a subsequent operative intervention. The rate of repeat surgeries varies by patient, tumor, and facility factors and has decreased slightly during the past 6 years.

Abstract P5-14-09: Brachytherapy, 3-dimentional conformal radiotherapy, and intensity modulated radiotherapy for breast cancer patients undergoing breast conservation: Effectiveness and guideline concordance

Background: There has been a rapid increase in the use of new radiation techniques for postlumpectomy radiation, including partial breast irradiation via brachytherapy (APBI-b), 3-dimentional conformal radiotherapy (3D-CRT), and intensity modulated radiotherapy (IMRT) techniques. However, it is unknown if these new radiation techniques provide survival benefit equivalent to external beam whole-breast irradiation (WBI) in patients undergoing breast conservation. Additionally, compliance with the 2009 ASTRO guidelines for partial breast radiation has not been examined in a contemporary cohort of patients. Method: From the National Cancer Database, we identified 718,392 women diagnosed with AJCC stage 0-III breast cancer between 2003 and 2010, who underwent breast conserving surgery. Patients were classified into suitable, cautionary, or unsuitable for APBI-b according to ASTRO guidelines. Cox proportional hazard models were used to examine the effectiveness of the new irradiation modalities on overall survival in all eligible patients and within each ASTRO category. Results: Overall, 37,363 patients (6.4%) underwent APBI-b, 40,767 (5.7%) underwent IMRT, 45,721 (6.4%) underwent 3D-CRT, 421,497 (58.7%) underwent conventional WBI. The utilization of the three new radiation techniques increased over the study period, and 31.3% of all patients treated with radiotherapy after lumpectomy actually used one of the three new methods in 2010. Overall, 35% of patients receiving APBI-b fell in the suitable category, 47% in the cautionary category, and 18% in the unsuitable category. After publication of the ASTRO guideline, the proportion of patients receiving APBI-b in the suitable category has increased from 34% in 2008 to 40% in 2010. After a median follow up of 46 months, 52,099 patients died. In invasive breast cancer patients, we found patients undergoing APBI-b had a 38% reduction in the risk of death, compared to patients without radiotherapy (hazard ratio, HR = 0.62, 95% CI: 0.57-0.66, p Conclusions: In a large cohort of women with early stage breast cancer, radiotherapy using three new techniques (APBI-b, IMRT, and 3D-CRT) was found to be as effective in reducing mortality as conventional whole breast irradiation. Although this is promising, long-term follow-up studies and randomized clinical trials are warranted. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-14-09.