AVOIDING REPEAT SURGERIES
In breast cancer surgery, taking just a little bit more healthy tissue initially can help patients avoid a return trip to the operating room. This surgical technique, known as resection of cavity shave margins, has been shown to reduce the rate of cancerous margins of a breast cancer surgical specimen and the need for repeat surgery by half in women undergoing breast conserving surgery. In this technique, surgeons remove additional tissue in the circumference of the cavity left by a partial mastectomy.
These findings were reported in a multi-center study of about 400 patients across the country that will be published in the Annals of Surgery.
Thankfully, most breast cancers are taken out at an early stage. But surgeons cannot see the tumor and must rely on the appearance of the tissue and their judgment to identify the location and extent of the cancer. The surgeon does not know whether the margins of the tumor are cancer-free until the pathology report comes back days later.
“Historically, 20 to 40 percent of the time we would end up with cancer cells at the edge and we would need to tell our patients we’d have to take them back for a second surgery. This is not a good situation for the surgeon, the patient or the health system,” said Dr. Anees Chagpar, a breast cancer surgeon at Yale’s Smilow Cancer Center, a professor at Yale School of Medicine and the senior author of the study.
“We wondered, simply by taking a little bit more tissue, could we reduce the positive [cancerous] margin?”
Chagpar answered that question affirmatively in a 2015 study published in the New England Journal of Medicine that looked at 235 Yale patients who were undergoing mastectomy.
“What we found in the study, by just taking a little more tissue, we could reduce the positive margin rate by 50 percent. It’s very exciting,” Chagpar said.
Even though surgeons took more tissue, there was no increase in the rate of wound closure problems or in short-term cosmetic results in that study.
The New England Journal of Medicine, in an accompanying editorial, called the study a strong step toward actual “evidence-based strategies that aim to maximize the rate of breast conservation, minimize reoperations and maintain cosmesis.”
Yale is a major academic medical center with fellowship-trained breast surgeons. Chagpar repeated the study to see if the same results could be achieved in a variety of settings like community hospitals without fellowships and in diverse geographic locations.
In the most recent study, patients were randomly assigned to a “shave” or to a “no shave” group. The study found that cancer was present at the edge of the sample at a rate of 9.7 percent in the “shave” group and 36.0 percent in the “no shave” group. In other words, the cancer was completely removed more often in the “shave” group than the “no shave” group. This is a highly statistically significant finding.
Some women who still have cancer at the edge of the sample require another operation. So Chagpar and her colleagues looked at how often another surgery was necessary. In the “shave” group, 8.7 percent of women needed a second surgery, in the “no shave” group, it was 23.5 percent, also statistically significant.
Avoiding a second surgery is important for a number of reasons, said Dr. Niamey Wilson, a breast cancer surgeon and director of research and quality for breast surgery at Hartford HealthCare.
A second surgery has a higher likelihood of infection and would delay going to the next phase of breast cancer treatment.
“The potential down side is the higher volume of tissue being removed,” Wilson said. “Most women would happily exchange that for not having to return to the operating room a second time.”
Wilson does perform the cavity shave technique; many surgeons do not.
“It’s quite practice-changing, but not adopted by all,” Wilson said. “Surgeons are so programmed in some ways to operate like they have always. Patients are going to see a drastically reduced possibility to have a second surgery. There’s nothing better than telling a patient, ‘We got it.’”
The research was funded by a variety of small foundations including the Connecticut Breast Health Initiative, which gave $50,000 of seed money to Chagpar in both 2013 and 2017.
The seed money enables researchers to prove the value of the work in order to get larger funding, said Joyce Bray, president of the board of directors.
“We love that it is a collaboration of nine participating sites. We liked the fact that it both physically and mentally saves women from a lot of stress. It’s definitely important and worthwhile work,” Bray said.
After the initial study, critics might have said that resection of cavity shave margins only works in an academic setting.
“What this study has shown is that it really does apply across the board,” Chagpar said.