Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data

Marina T van Leeuwen, Michael O Falster, Claire M Vajdic, Philip J Crowe, Sanja Lujic, Elizabeth Klaes, Louisa Jorm, Art Sedrakyan, Marina T van Leeuwen, Michael O Falster, Claire M Vajdic, Philip J Crowe, Sanja Lujic, Elizabeth Klaes, Louisa Jorm, Art Sedrakyan

Abstract

Objectives: To investigate between-hospital variation in the probability of reoperation within 90 days of initial breast-conserving surgery (BCS), and the contribution of health system-level and other factors.

Design: Population-based, retrospective cohort study.

Setting: New South Wales (NSW), Australia.

Participants: Linked administrative hospitalisation data were used to define a cohort of adult women undergoing initial BCS for breast cancer in NSW between 1 July 2002 and 31 December 2013.

Primary outcome measures: Multilevel, cross-classified models with patients clustered within hospitals and residential areas were used to examine factors associated with any reoperation, and either re-excision or mastectomy, within 90 days.

Results: Of 34 458 women undergoing BCS, 29.1% underwent reoperation within 90 days, half of which were mastectomies. Overall, the probability of reoperation decreased slightly over time. However, there were divergent patterns by reoperation type; the probability of re-excision increased alongside a concomitant decrease in the probability of mastectomy. Significant between-hospital variation was observed. Non-metropolitan location and surgery at low-volume hospitals were associated with a higher overall probability of reoperation, and of mastectomy specifically, after accounting for patient-level factors, calendar year and area-level socioeconomic status. The magnitude of association with geographical location and surgical volume decreased over time.

Conclusions: Reoperation rates within 90 days of BCS varied significantly between hospitals. For women undergoing mastectomy after BCS, this represents a dramatic change in clinical course. Multilevel modelling suggests unwarranted clinical variation may be an issue, likely due to disparities in access to multidisciplinary breast cancer care and preoperative diagnostic procedures. However, the observed reduction in disparities over time is encouraging and indicates that guidelines and policy initiatives have the potential to improve regional breast cancer care.

Keywords: breast cancer; breast conserving surgery; cohort; health services research; reoperation.

Conflict of interest statement

Competing interests: None declared.

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Figures

Figure 1
Figure 1
Flow diagram showing study inclusion and exclusion criteria. BCS, breast-conserving surgery; NSW, New South Wales.
Figure 2
Figure 2
Adjusted ORs for any reoperation versus no reoperation, and separately, for re-excision or mastectomy versus no reoperation within 90 days of initial breast-conserving surgery (BCS), New South Wales, Australia, 2002–2013. Shows ORs for calendar year and health system-level factors fully adjusted for patient-level and area-level contextual factors based on multilevel, cross-classified binomial (any reoperation) and multinomial (re-excision, mastectomy) logistic regression models.
Figure 3
Figure 3
Population-averaged predicted probabilities of any reoperation, and separately, of re-excision or mastectomy, within 90 days of initial breast-conserving surgery, by calendar year and location, New South Wales, Australia, 2002–2013. Predicted probabilities obtained from fully adjusted multilevel, cross-classified binomial (any reoperation) and multinomial (re-excision, mastectomy) logistic regression models containing interaction terms between discrete calendar years geographical location. For illustrative purposes, graph restricted to concordant metropolitan or non-metropolitan residential and hospital location.

References

    1. National Health and Medical Research Council. Clinical practice guidelines for the managment of early breast cancer. 2nd edition Canberra: Commonwealth of Australia, 2001. (accessed 4 Apr 2017).
    1. Senkus E, Kyriakides S, Ohno S, et al. . Primary breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015;26(Suppl 5):v8–v30. 10.1093/annonc/mdv298
    1. Litière S, Werutsky G, Fentiman IS, et al. . Breast conserving therapy versus mastectomy for stage I-II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol 2012;13:412–9. 10.1016/S1470-2045(12)70042-6
    1. Pyfer B, Chatterjee A, Chen L, et al. . Early postoperative outcomes in breast conservation surgery versus simple mastectomy with implant reconstruction: a NSQIP analysis of 11,645 patients. Ann Surg Oncol 2016;23:92–8. 10.1245/s10434-015-4770-2
    1. Engel J, Kerr J, Schlesinger-Raab A, et al. . Quality of life following breast-conserving therapy or mastectomy: results of a 5-year prospective study. Breast J 2004;10:223–31. 10.1111/j.1075-122X.2004.21323.x
    1. Roder D, Zorbas H, Kollias J, et al. . Factors predictive of treatment by Australian breast surgeons of invasive female breast cancer by mastectomy rather than breast conserving surgery. Asian Pac J Cancer Prev 2013;14:539–45. 10.7314/APJCP.2013.14.1.539
    1. Baade PD, Dasgupta P, Youl PH, et al. . Geographical inequalities in surgical treatment for localized female breast cancer, Queensland, Australia 1997-2011: improvements over time but inequalities remain. Int J Environ Res Public Health 2016;13:729 10.3390/ijerph13070729
    1. Spilsbury K, Semmens JB, Saunders CM, et al. . Subsequent surgery after initial breast conserving surgery: a population based study. ANZ J Surg 2005;75:260–4. 10.1111/j.1445-2197.2005.03352.x
    1. Habermann EB, Abbott A, Parsons HM, et al. . Are mastectomy rates really increasing in the United States? J Clin Oncol 2010;28:3437–41. 10.1200/JCO.2009.27.6774
    1. Isaacs AJ, Gemignani ML, Pusic A, et al. . Association of breast conservation surgery for cancer with 90-day reoperation rates in New York State. JAMA Surg 2016;151:648–55. 10.1001/jamasurg.2015.5535
    1. Jeevan R, Cromwell DA, Trivella M, et al. . Reoperation rates after breast conserving surgery for breast cancer among women in England: retrospective study of hospital episode statistics. BMJ 2012;345:e4505 10.1136/bmj.e4505
    1. Heil J, Breitkreuz K, Golatta M, et al. . Do reexcisions impair aesthetic outcome in breast conservation surgery? Exploratory analysis of a prospective cohort study. Ann Surg Oncol 2012;19:541–7. 10.1245/s10434-011-1947-1
    1. Menes TS, Tartter PI, Bleiweiss I, et al. . The consequence of multiple re-excisions to obtain clear lumpectomy margins in breast cancer patients. Ann Surg Oncol 2005;12:881–5. 10.1245/ASO.2005.03.021
    1. Pataky RE, Baliski CR. Reoperation costs in attempted breast-conserving surgery: a decision analysis. Curr Oncol 2016;23:314–21. 10.3747/co.23.2989
    1. Morrow M, Abrahamse P, Hofer TP, et al. . Trends in Reoperation after initial lumpectomy for breast cancer: addressing overtreatment in surgical management. JAMA Oncol 2017;3:1352-1357 10.1001/jamaoncol.2017.0774
    1. Hughes L, Hamm J, McGahan C, et al. . Surgeon volume, patient age, and tumor-related factors influence the need for re-excision after breast-conserving surgery. Ann Surg Oncol 2016;23:656–64. 10.1245/s10434-016-5602-8
    1. de Camargo Cancela M, Comber H, Sharp L. Hospital and surgeon caseload are associated with risk of re-operation following breast-conserving surgery. Breast Cancer Res Treat 2013;140:535–44. 10.1007/s10549-013-2652-5
    1. Quan H, Sundararajan V, Halfon P, et al. . Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 2005;43:1130–9. 10.1097/01.mlr.0000182534.19832.83
    1. Australian Bureau of Statistics. Census of Population and Housing: Socio-Economic Indexes for Areas (SEIFA), Australia 2006. Canberra: Australian Bureau of Statistics, 2008. updated 10 July 2017. ABS Catalogue no. 2033.0.55.001 (accessed 10 Jul 2017).
    1. Australian Bureau of Statistics. Statistical Geography Volume 1 - Australian Standard Geographical Classification (ASGC). Canberra: Australian Bureau of Statistics, 2006. updated 10 July 2017. ABS Catalogue no. 1216.0 [Available (accessed 10 Jul 2017).
    1. Merlo J, Yang M, Chaix B, et al. . A brief conceptual tutorial on multilevel analysis in social epidemiology: investigating contextual phenomena in different groups of people. J Epidemiol Community Health 2005;59:729–36. 10.1136/jech.2004.023929
    1. Blyth CR. On simpson’s paradox and the sure-thing principle. J Am Stat Assoc 1972;67:364–6. 10.1080/01621459.1972.10482387
    1. Kemp A, Preen DB, Saunders C, et al. . Ascertaining invasive breast cancer cases; the validity of administrative and self-reported data sources in Australia. BMC Med Res Methodol 2013;13:17 10.1186/1471-2288-13-17
    1. McGeechan K, Kricker A, Armstrong B, et al. . Evaluation of linked cancer registry and hospital records of breast cancer. Aust N Z J Public Health 1998;22:765–70. 10.1111/j.1467-842X.1998.tb01490.x
    1. Talsma AK, Reedijk AM, Damhuis RA, et al. . Re-resection rates after breast-conserving surgery as a performance indicator: introduction of a case-mix model to allow comparison between Dutch hospitals. Eur J Surg Oncol 2011;37:357–63. 10.1016/j.ejso.2011.01.008
    1. Escribà JM, Esteban L, Gálvez J, et al. . Reoperations after primary breast conserving surgery in women with invasive breast cancer in Catalonia, Spain: a retrospective study. Clin Transl Oncol 2017;19:448–56. 10.1007/s12094-016-1546-5
    1. Landercasper J, Whitacre E, Degnim AC, et al. . Reasons for re-excision after lumpectomy for breast cancer: insight from the American Society of Breast Surgeons Mastery(SM) database. Ann Surg Oncol 2014;21:3185–91. 10.1245/s10434-014-3905-1
    1. Houssami N, Macaskill P, Marinovich ML, et al. . The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol 2014;21:717–30. 10.1245/s10434-014-3480-5
    1. Marinovich ML, Azizi L, Macaskill P, et al. . The association of surgical margins and local recurrence in women with ductal carcinoma in situ treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol 2016;23:3811–21. 10.1245/s10434-016-5446-2
    1. Moran MS, Schnitt SJ, Giuliano AE, et al. . Society of surgical oncology-american society for radiation oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages i and ii invasive breast cancer. J Clin Oncol 2014;32:1507–15. 10.1200/JCO.2013.53.3935
    1. Morrow M, Van Zee KJ, Solin LJ, et al. . Society of surgical oncology-american society for radiation oncology-american society of clinical oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. J Clin Oncol 2016;34:4040–6. 10.1200/JCO.2016.68.3573
    1. McCahill LE, Single RM, Aiello Bowles EJ, et al. . Variability in reexcision following breast conservation surgery. JAMA 2012;307:467–75. 10.1001/jama.2012.43
    1. Eberth JM, Xu Y, Smith GL, et al. . Surgeon influence on use of needle biopsy in patients with breast cancer: a national medicare study. J Clin Oncol 2014;32:2206–16. 10.1200/JCO.2013.52.8257
    1. Chang JH, Vines E, Bertsch H, et al. . The impact of a multidisciplinary breast cancer center on recommendations for patient management: the University of Pennsylvania experience. Cancer 2001;91:1231–7.
    1. Marsh CJ, Boult M, Wang JX, et al. . National Breast Cancer Audit: the use of multidisciplinary care teams by breast surgeons in Australia and New Zealand. Med J Aust 2008;188:385–8.
    1. Azzopardi J, Walsh D, Chong C, et al. . Impact of geographic location on surgical outcomes of women with breast cancer. ANZ J Surg 2014;84:735–9. 10.1111/ans.12514
    1. Australian Institute of Health and Welfare (AIHW) and Cancer Australia. Breast Cancer in Australia: An Overview. Canberra: AIHW, 2012. Cancer series no. 71. Cat. no. CAN 67 (accessed 7 Jun 2017).
    1. Wilke LG, Czechura T, Wang C, et al. . Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. JAMA Surg 2014;149:1296-305 10.1001/jamasurg.2014.926
    1. Vrieling C, Collette L, Fourquet A, et al. . Can patient-, treatment- and pathology-related characteristics explain the high local recurrence rate following breast-conserving therapy in young patients? Eur J Cancer 2003;39:932–44. 10.1016/S0959-8049(03)00123-0
    1. Wang J, Kollias J, Boult M, et al. . Patterns of surgical treatment for women with breast cancer in relation to age. Breast J 2010;16:60–5. 10.1111/j.1524-4741.2009.00828.x
    1. Rajaram N, Mariapun S, Eriksson M, et al. . Differences in mammographic density between Asian and Caucasian populations: a comparative analysis. Breast Cancer Res Treat 2017;161:353–62. 10.1007/s10549-016-4054-y
    1. Skinner KA, Silberman H, Sposto R, et al. . Palpable breast cancers are inherently different from nonpalpable breast cancers. Ann Surg Oncol 2001;8:705–10. 10.1007/s10434-001-0705-1
    1. Langhans L, Jensen MB, Talman MM, et al. . Reoperation rates in ductal carcinoma in situ vs invasive breast cancer after wire-guided breast-conserving surgery. JAMA Surg 2017;152:378–84. 10.1001/jamasurg.2016.4751
    1. van Deurzen CH. Predictors of surgical margin following breast-conserving surgery: a large population-based cohort study. Ann Surg Oncol 2016;23:627–33. 10.1245/s10434-016-5532-5
    1. Roder D, Webster F, Zorbas H, et al. . Breast screening and breast cancer survival in Aboriginal and Torres Strait Islander women of Australia. Asian Pac J Cancer Prev 2012;13:147–55. 10.7314/APJCP.2012.13.1.147
    1. Azzopardi J, Walsh D, Chong C, et al. . Surgical treatment for women with breast cancer in relation to socioeconomic and insurance status. Breast J 2014;20:3–8. 10.1111/tbj.12203
    1. Dasgupta P, Youl PH, Pyke C, et al. . Geographical disparity in breast reconstruction following mastectomy has reduced over time. ANZ J Surg 2017;87:E183–7. 10.1111/ans.13710
    1. Landercasper J, Attai D, Atisha D, et al. . Toolbox to reduce lumpectomy reoperations and improve cosmetic outcome in breast cancer patients: the american society of breast surgeons consensus conference. Ann Surg Oncol 2015;22:3174–83. 10.1245/s10434-015-4759-x
    1. Murphy C, Sabesan S, Steer C, et al. . Oncology service initiatives and research in regional Australia. Aust J Rural Health 2015;23:40–8. 10.1111/ajr.12173
    1. Fox P, Boyce A. Cancer health inequality persists in regional and remote Australia. Med J Aust 2014;201:445–6. 10.5694/mja14.01217

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren