Anita Mamtani1, Anya Romanoff2, Raymond Baser3, Alain Vincent4, Monica Morrow4, Mary L Gemignani4. 1. Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA. mamtana1@mskcc.org. 2. Breast Surgery, Dubin Breast Center, Icahn School of Medicine at The Mount Sinai Hospital, New York, NY, USA. 3. Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA. 4. Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
Abstract
BACKGROUND: Historically, more than one-third of patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) underwent additional surgery. The SSO-ASTRO guidelines advise 2 mm margins for patients with DCIS having BCS and whole-breast radiation (WBRT). Here we examine guideline impact on additional surgery and factors associated with re-excision. PATIENTS AND METHODS: Patients treated with BCS for pure DCIS from August 2015 to January 2018 were identified. Guidelines were adopted on September 1, 2016, and all patients had separately submitted cavity-shave margins. Clinicopathologic characteristics, margin status, and rates of additional surgery were examined. RESULTS: Among 650 patients with DCIS who attempted BCS, 50 (8%) converted to mastectomy. Of 600 who had BCS as final surgery, 336 (56%) received WBRT and comprised our study group. One hundred twenty-eight (38%) were treated pre-guideline and 208 (62%) were treated post-guideline. Characteristics and margin status were similar between groups. The re-excision rate was 38% pre-guideline adoption and 29% post-guideline adoption (p = 0.09), with 91% having only one re-excision. Re-excision for ≥ 2 mm margins was uncommon (6% pre-guideline vs. 5% post-guideline). On multivariate analysis, younger age (OR 0.97, 95% CI 0.94-0.99, p = 0.02) and larger DCIS size (OR 1.43, 95% CI 1.2-1.8, p < 0.001) were predictive of re-excision; guideline era was not. Younger age (OR 0.93, 95% CI 0.9-0.97, p < 0.001) and larger size (OR 1.64, 95% CI 1.3-2.1, p < 0.001) were predictive of conversion to mastectomy, but residual tumor burden was low. CONCLUSIONS: The SSO-ASTRO guidelines did not significantly change re-excision rates for DCIS in our practice, likely since re-excision for margins ≥ 2 mm was uncommon even prior to guideline adoption, dissimilar to historically observed variations in surgeon practices. Younger age and larger DCIS size were associated with additional surgery.
BACKGROUND: Historically, more than one-third of patients with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS) underwent additional surgery. The SSO-ASTRO guidelines advise 2 mm margins for patients with DCIS having BCS and whole-breast radiation (WBRT). Here we examine guideline impact on additional surgery and factors associated with re-excision. PATIENTS AND METHODS: Patients treated with BCS for pure DCIS from August 2015 to January 2018 were identified. Guidelines were adopted on September 1, 2016, and all patients had separately submitted cavity-shave margins. Clinicopathologic characteristics, margin status, and rates of additional surgery were examined. RESULTS: Among 650 patients with DCIS who attempted BCS, 50 (8%) converted to mastectomy. Of 600 who had BCS as final surgery, 336 (56%) received WBRT and comprised our study group. One hundred twenty-eight (38%) were treated pre-guideline and 208 (62%) were treated post-guideline. Characteristics and margin status were similar between groups. The re-excision rate was 38% pre-guideline adoption and 29% post-guideline adoption (p = 0.09), with 91% having only one re-excision. Re-excision for ≥ 2 mm margins was uncommon (6% pre-guideline vs. 5% post-guideline). On multivariate analysis, younger age (OR 0.97, 95% CI 0.94-0.99, p = 0.02) and larger DCIS size (OR 1.43, 95% CI 1.2-1.8, p < 0.001) were predictive of re-excision; guideline era was not. Younger age (OR 0.93, 95% CI 0.9-0.97, p < 0.001) and larger size (OR 1.64, 95% CI 1.3-2.1, p < 0.001) were predictive of conversion to mastectomy, but residual tumor burden was low. CONCLUSIONS: The SSO-ASTRO guidelines did not significantly change re-excision rates for DCIS in our practice, likely since re-excision for margins ≥ 2 mm was uncommon even prior to guideline adoption, dissimilar to historically observed variations in surgeon practices. Younger age and larger DCIS size were associated with additional surgery.
Authors: Sarah M DeSnyder; Kelly K Hunt; Wenli Dong; Benjamin D Smith; Meena S Moran; Mariana Chavez-MacGregor; Yu Shen; Henry M Kuerer; Anthony Lucci Journal: Ann Surg Oncol Date: 2018-07-09 Impact factor: 5.344
Authors: Laura H Rosenberger; Anita Mamtani; Sarah Fuzesi; Michelle Stempel; Anne Eaton; Monica Morrow; Mary L Gemignani Journal: Ann Surg Oncol Date: 2016-07-12 Impact factor: 5.344
Authors: Irene L Wapnir; James J Dignam; Bernard Fisher; Eleftherios P Mamounas; Stewart J Anderson; Thomas B Julian; Stephanie R Land; Richard G Margolese; Sandra M Swain; Joseph P Costantino; Norman Wolmark Journal: J Natl Cancer Inst Date: 2011-03-11 Impact factor: 13.506
Authors: Monica Morrow; Reshma Jagsi; Amy K Alderman; Jennifer J Griggs; Sarah T Hawley; Ann S Hamilton; John J Graff; Steven J Katz Journal: JAMA Date: 2009-10-14 Impact factor: 56.272
Authors: Monica Morrow; Kimberly J Van Zee; Lawrence J Solin; Nehmat Houssami; Mariana Chavez-MacGregor; Jay R Harris; Janet Horton; Shelley Hwang; Peggy L Johnson; M Luke Marinovich; Stuart J Schnitt; Irene Wapnir; Meena S Moran Journal: J Clin Oncol Date: 2016-10-31 Impact factor: 44.544
Authors: Kate R Pawloski; Nicole Christian; Andrea Knezevic; Hannah Y Wen; Kimberly J Van Zee; Monica Morrow; Audree B Tadros Journal: Breast Cancer Res Treat Date: 2020-08-28 Impact factor: 4.872