Breast Cancer Surgery Rules Are Called Unclear
But how big should the margins be? When the tumor and the healthy tissue are removed, the surface of the whole specimen is inked so that when it is sliced and seen through a microscope, the pathologist can use the ink marks to find the margins between the cancer and the healthy tissue and measure how close the cancer cells are.
Some surgeons consider the operation complete if no cancer cells are touching ink. Others want a wider margin of healthy tissue between the cancer cells and the ink: one, two or even five millimeters. If there is less, they operate again.
Surgeons say some radiation and medical oncologists insist on a certain margin size before starting the rest of the patient’s treatment. The decision to reoperate also depends in part on what type of tumor the patient has. But there is no evidence that a margin any bigger than “not touching ink” affects cancer recurrence or survival, said Dr. Morrow, who wrote an editorial accompanying the study. At her hospital, she said, “not touching ink” is generally considered good enough.
When is lumpectomy plus radiation an option?
Lumpectomy plus radiation is an option for most women, including those who have ductal carcinoma in situ or early breast cancer. In some cases, it is also an option for women with locally advanced breast cancer.
Women with certain health conditions cannot have radiation therapy and may need to have a mastectomy instead of a lumpectomy. These conditions include:
- Scleroderma or systemic lupus. These disorders can keep tissue from healing correctly after radiation therapy.
- Past radiation therapy to the same breast. In general, radiation therapy to the breast can only be given once. (In rare cases, radiation to the same breast may be repeated.)
- Pregnancy. Radiation can harm a fetus, so it is not given during pregnancy. However, depending on the timing of the pregnancy and breast cancer diagnosis, a woman may be able to have a lumpectomy and put off radiation therapy until after delivery.
When a large amount of breast tissue must be removed to get rid of the tumor(s), a mastectomy may be the better surgical option. This may be the case when:
There are two or more tumors in different areas of the breast (multi-centric tumors).
The tumor is quite large (relative to breast size).
The tumor has spread throughout the breast (diffuse tumor).
The tumor is located just beneath the nipple (such that cosmetic look after lumpectomy will not be good).
The surgical team cannot get negative margins (remove all the tumor) with multiple attempts by lumpectomy.
Many doctors think bigger margins must be safer, Dr. Morrow said, but studies indicate that they are not.
“We really could decrease a significant amount of surgery that women are getting if we could come to a consensus that in this era, bigger is not necessarily better,” Dr. Morrow said.
Nearly all women now receive additional treatment after lumpectomy — radiation and systemic treatment with chemotherapy or hormones or both — and those treatments have greatly lowered the recurrence rate and have made margin size less of a concern than in the past, Dr. Morrow said.
Lumpectomy is the most common operation for breast cancer; it is performed in 60 percent to 75 percent of the more than 200,000 new cases per year in the United States. It began coming into use about 30 years ago as a means of sparing women from what had been the standard treatment, mastectomy, or removing the entire breast. Major studies begun in the 1970s transformed the field by showing that in most cases, women who had lumpectomy and radiation lived just as long as those who had mastectomies.
But lumpectomy has always been a balancing act between trying to remove the whole tumor and preserve the breast, said Dr. Stephen R. Grobmyer, a breast cancer surgeon at the University of Florida in Gainesville.
Cancer can spread in ways that do not show up on mammograms and that surgeons cannot see or feel in the operating room, so repeat operations have been considered inevitable for some women.
Previous smaller studies have found repeat operation rates of 30 percent to 60 percent.
“I don’t think you’ll have a lot of argument from women or insurers that doing something twice 30 percent of the time isn’t the way to go,” Dr. McCahill said, adding that the repeat operations were physically and mentally difficult for women and were an added expense.
What the repeat rate should be is not known, but surgeons interviewed for this article thought 50 percent or higher was cause for concern. They said there was no evidence that doctors operated more than once on cancer patients just to make money.
Doctors cautioned that it would be a mistake to look for surgeons with a low rate of repeat operations. Dr. Susan K. Boolbol, the chief of breast surgery at Beth Israel Hospital in Manhattan, cautioned that a low rate could mean that the surgeon usually did the operation right the first time — but could also mean that the surgeon did a lot of mastectomies or failed to operate again after lumpectomy even when more surgery was needed.
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By DENISE GRADY