Breast Cancer Surgery Rules Are Called Unclear
Nearly half of women who had lumpectomies for breast cancer had second operations they may not have needed because surgeons have been unable to agree on guidelines for the most common operation for breast cancer, a new study finds. It also hints that some women who might benefit from further surgery may be missing out on it.
Rates of repeat surgery can vary widely by doctor, from zero percent to 70 percent, according to the study.
The additional operations are done when pathology reports on tumor specimens suggest that the first operation may have left behind some cancer cells. But surgeons differ when it comes to interpreting those reports.
Such uncertainty about a cancer operation that has been in use for 30 years is “a shame,” said Dr. Laurence E. McCahill, the first author of the study and a surgeon and assistant director of the Lacks Cancer Center in Grand Rapids, Mich. Dr. Monica Morrow, the chief of breast surgery at Memorial Sloan-Kettering Cancer Center in New York, said the study and attention from the public might help push professional groups to develop guidelines for surgeons. The details of surgery are not regulated, but surgeons generally follow expert advice.
“It is getting to be the time for leaders in radiation oncology and surgery to get together and make a consensus statement that could help to guide their membership,” Dr. Morrow said.
Dr. McCahill’s study, published online Tuesday by The Journal of the American Medical Association, is based on the medical records of 2,206 women who had lumpectomies at one of four hospitals in different parts of the country. Over all, 22.9 percent had more than one operation.
Nearly half of the repeat operations were done in women whose pathology reports did not indicate that any stray cancer cells had been left behind, meaning that the operations probably did not help the patients. In more disturbing findings, 14 percent of patients who did have evidence of cancer left behind did not have another operation, for unknown reasons.
Rates of repeat surgery varied by surgeon, and by hospital, from 1.7 percent to 20.9 percent. Differences in the patients did not account for most of the variation, though very thin women, who tend to have small breasts, were more likely to need second operations. Surgeons say that is because they try to remove as little tissue as possible from small breasts for cosmetic reasons.
“The number of operations women undergo definitely depends on where you’re treated, and even to a greater level on which surgeon you see,” Dr. McCahill said. “We put the math behind it and said, this is a lot of second operations that maybe don’t make a difference.”
Dr. McCahill said that such high repeat operation rates did not occur in other types of cancer surgery, in part because surgeons are not trying to spare tissue for cosmetic reasons as they are in lumpectomy.
Lumpectomy is the removal of the breast tumor (the “lump”) and some of the normal tissue that surrounds it. Lumpectomy is a form of “breast-conserving” or “breast preservation” surgery. There are several names used for breast-conserving surgery: biopsy, lumpectomy, partial mastectomy, re-excision, quadrantectomy, or wedge resection. Technically, a lumpectomy is a partial mastectomy, because part of the breast tissue is removed. But the amount of tissue removed can vary greatly. Quadrantectomy, for example, means that roughly a quarter of your breast will be removed. Make sure you have a clear understanding from your surgeon about how much of your breast may be gone after surgery and what kind of scar you will have.
What happens during lumpectomy surgery
The lumpectomy surgery itself should take about 15-40 minutes.
Your surgeon will probably operate with a kind of electric scalpel that uses heat to minimize bleeding (an electrocautery knife). Most surgeons use curved incisions (like a smile or a frown) that follow the natural curve of your breast and allow for better healing. If the tumor can be seen or felt, the surgeon will remove it along with a rim of healthy tissue around it.
Sometimes, but not always, a rubber tube called a drain will be surgically inserted into your breast area or armpit to collect excess fluid that can accumulate in the space where the tumor was. The drain is connected to a plastic bulb that creates suction to help remove fluid. Finally, your surgeon will stitch the incision closed and dress the wound.
A major reason for the variation in repeat operations after lumpectomy is that there is no consensus among surgeons about how big a rim or “margin” of healthy tissue should be taken out when a cancer is removed. Surgeons try to cut cleanly around a tumor and remove enough of a margin to ensure that they excised all the cancer.
Negative or clean margins generally mean the whole tumor was removed. Positive margins mean some cancer was probably left behind and another operation is needed to prevent recurrence.