Variability in reexcision following breast conservation surgery.
BACKGROUND
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.


METHODS
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.


METHODS
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).


CONCLUSIONS
Substantial surgeon and institutional variation were observed in reexcision following partial mastectomy in women with invasive breast cancer.
Richard J. Lacks Cancer Center, Van Andel Research Institute, and Department of Surgery, Michigan State University, Grand Rapids, MI 49503, USA. mccahill@trinity-health.org
Laurence E
LE
McCahill
Richard M
RM
Single
Erin J
EJ
Aiello Bowles
Heather S
HS
Feigelson
Ted A
TA
James
Tom
T
Barney
Jessica M
JM
Engel
Adedayo A
AA
Onitilo
D000328:Adult; D000368:Aged; D001943:Breast Neoplasms / Q000473:pathology / Q000601:surgery*; D005260:Female; D006801:Humans; D015412:Mastectomy, Segmental / Q000592:standards* / Q000706:statistics & numerical data; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D017063:Outcome Assessment, Health Care; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012086:Reoperation / Q000706:statistics & numerical data*; D014481:United States