为了获得更宽的阴性切缘，初次乳房肿块切除术后再次手术十分普遍，由此可能导致乳房全部切除术。
2014年，美国临床肿瘤学会、外科肿瘤学会、美国放射肿瘤学会联合发表I～II期浸润性乳腺癌全乳放疗＋保乳手术的切缘共识指南。那么，2014年共识声明认可浸润性乳腺癌最少阴性切缘对于乳房肿块切除术后再次手术和最终手术治疗的影响如何？
2017年6月5日，《美国医学会杂志肿瘤学分册》在线发表纪念斯隆凯特林癌症中心、密歇根大学、美国退伍军人事务部临床管理研究中心、埃默里大学、南加利福尼亚大学、斯坦福大学的队列研究报告，描述了外科医生处理浸润性乳腺癌手术切缘的方法、乳房肿块切除术后再次手术率的变迁、2014年共识声明认可“肿瘤无墨”切缘后的最终手术治疗。结果发现，在2013～2015年进行乳房肿块切除术的3729例女性人群样本中，阴性切缘患者的再次乳房肿块切除术和乳房全部切除术减少，最终乳房保留手术率由52%增至65%，单侧和双侧乳房全部切除术均减少。因此，初次乳房肿块切除术后再次手术减少，增加了乳房保留手术率，符合循证指南加速实践变化以减少过度治疗的初衷。
该人群队列调查问卷研究从佐治亚州（2015年人口1021万）和加利福尼亚州洛杉矶县（包括洛杉矶市，2014年人口1012万）的监测、流行病学与最终结果（SEER）数据登记处筛选出7303例年龄20～79岁2013～2015年诊断为I～II期乳腺癌的女性，其中共有5080例（70%）反馈了调查问卷。排除了双侧病变、缺少分期或治疗数据、导管原位癌患者后，其余3729例患者进入分析样本，其中98%确定其主治外科医生。2015年4月～2016年5月，向上述患者的488位外科医生发送了关于乳房肿块切除术切缘的调查问卷，其中342位（70%）反馈完整。对所有再次手术患者的病理报告和一次手术患者的30%样本进行复核。使用多变量回归模型分析时间趋势。主要结局衡量指标为最终手术率（乳房肿块切除术、单侧乳房全部切除术、双侧乳房全部切除术）和初次乳房肿块切除术后再次手术率的时间变化，以及外科医生对乳房肿块切除术足够切缘的态度。
结果发现，在3729例患者分析样本中，初次乳房肿块切除术率为67%，研究期间始终未变。最终乳房肿块切除术率由2013年52%增至2015年65%，增加了13%，伴单侧和双侧乳房全部切除术减少（P=0.002）。初次乳房肿块切除术后再次手术减少16%（P＜0.001）。病理复核发现治疗日期与阳性切缘之间无显著相关性。在342位反馈调查问卷的外科医生中，认可“肿瘤无墨”切缘以避免ER阳性且PR阳性、ER阴性且PR阴性癌症复发者分别占69%、63%。每年治疗乳腺癌≥50例与≤20例的外科医生相比，表示该切缘足够者较多（85%比55%，P＜0.001）。
因此，从2013年到2015年，随着临床指南认可最少阴性切缘的推广，初次乳房肿块切除术后的再次手术率下降。这些结果表明，外科医生带头解决潜在过度治疗的倡议，可以减轻癌症患者外科手术的负担。
相关阅读
JAMA Oncol. 2017 Jun 5. [Epub ahead of print]
Trends in Reoperation After Initial Lumpectomy for Breast Cancer: Addressing Overtreatment in Surgical Management.
Monica Morrow; Paul Abrahamse; Timothy P. Hofer; Kevin C. Ward; Ann S. Hamilton; Allison W. Kurian; Steven J. Katz; Reshma Jagsi.
Memorial Sloan Kettering Cancer Center, New York, New York; University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development Service Center of Innovation, Ann Arbor, Michigan; Emory University, Atlanta, Georgia; University of Southern California, Los Angeles; Stanford University, Stanford, California.
This cohort study describes surgeons' approach to surgical margins for invasive breast cancer, changes in postlumpectomy surgery rates, and final surgical treatment following a 2014 consensus statement endorsing a margin of "no ink on tumor."
QUESTION: What was the impact of a 2014 consensus statement endorsing a minimal negative margin for invasive breast cancer on postlumpectomy surgery and final surgical treatment?
FINDINGS: In a population-based sample of 3729 women undergoing initial lumpectomy between 2013 and 2015, reexcision and conversion to mastectomy declined significantly among patients with negative margins, and final rates of breast-conserving surgery increased from 52% to 65% with a decrease in both unilateral and bilateral mastectomy.
MEANING: The decrease in additional surgery after initial lumpectomy increased rates of breast-conserving surgery, consistent with a benefit of evidence-based guidelines in accelerating practice change to reduce overtreatment.
IMPORTANCE: Surgery after initial lumpectomy to obtain more widely clear margins is common and may lead to mastectomy.
OBJECTIVE: To describe surgeons' approach to surgical margins for invasive breast cancer, and changes in postlumpectomy surgery rates, and final surgical treatment following a 2014 consensus statement endorsing a margin of "no ink on tumor."
DESIGN, SETTING, AND PARTICIPANTS: This was a population-based cohort survey study of 7303 eligible women ages 20 to 79 years with stage I and II breast cancer diagnosed in 2013 to 2015 and identified from the Georgia and Los Angeles County, California, Surveillance, Epidemiology, and End Results registries. A total of 5080 (70%) returned a survey. Those with bilateral disease, missing stage or treatment data, and with ductal carcinoma in situ were excluded, leaving 3729 patients in the analytic sample; 98% of these identified their attending surgeon. Between April 2015 and May 2016, 488 surgeons were surveyed regarding lumpectomy margins; 342 (70%) responded completely. Pathology reports of all patients having a second surgery and a 30% sample of those with 1 surgery were reviewed. Time trends were analyzed with multinomial regression models.
MAIN OUTCOMES AND MEASURES: Rates of final surgical procedure (lumpectomy, unilateral mastectomy, bilateral mastectomy) and rates of additional surgery after initial lumpectomy over time, and surgeon attitudes toward an adequate lumpectomy margin.
RESULTS: The 67% rate of initial lumpectomy in the 3729 patient analytic sample was unchanged during the study. The rate of final lumpectomy increased by 13% from 2013 to 2015, accompanied by a decrease in unilateral and bilateral mastectomy (P=.002). Surgery after initial lumpectomy declined by 16% (P<.001). Pathology review documented no significant association between date of treatment and positive margins. Of 342 responding surgeons, 69% endorsed a margin of no ink on tumor to avoid reexcision in estrogen receptor-positive progesterone receptor-positive cancer and 63% for estrogen receptor-negative progesterone- receptor-negative cancer. Surgeons treating more than 50 breast cancers annually were significantly more likely to report this margin as adequate (85%; n=105) compared with those treating 20 cases or fewer (55%; n=131) (P<.001).
CONCLUSIONS AND RELEVANCE: Additional surgery after initial lumpectomy decreased markedly from 2013 to 2015 concomitant with dissemination of clinical guidelines endorsing a minimal negative margin. These findings suggest that surgeon-led initiatives to address potential overtreatment can reduce the burden of surgical management in patients with cancer.
DOI: 10.1001/jamaoncol.2017.0774
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