Yale: Taking More Breast Tissue Reduces Need For Second Surgery

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Breast cancer patients who have additional tissue removed during a partial mastectomy are half as likely to need a second surgery, according to a Yale Cancer Center study released today.

The study could have a major impact on thousands of patients, sparing them a second operation, according to researchers.

“No one likes going back to the operating room, especially not the patients who face the emotional burden of another surgery,” said Dr. Anees Chagpar, the study’s lead author, associate professor of surgery at Yale School of Medicine and director of The Breast Center, Smilow Cancer Hospital at Yale-New Haven.

Nearly 300,000 women nationwide are diagnosed with breast cancer each year. Most of them have early stages of the disease, and more than half of those undergo partial mastectomies to remove the cancer, Chagpar said.

Of those who have the operation, 20 percent to 40 percent have “positive margins,” or cancer cells found at the edge of what is removed, she said. Generally, those cancer cells at the edge can’t be detected until after the surgery, when the extracted tissue surrounding the cancer can be tested. Those remaining positive margins are what typically lead to second surgeries to make sure all of the cancer is gone.

“One of the things that many women struggle with is the emotional impact of going back into the operating room to get clear margins,” Chagpar said. “We thought, ‘Is there a way to do this better?’ ”

In the Yale study, researchers examined how removing more tissue all the way around the tumor site during the partial mastectomy – known as cavity shave margins – could reduce the need for a second operation.

The findings were published online today in the New England Journal of Medicine, and are being presented this weekend at the 2015 Annual Meeting of the American Society of Clinical Oncology in Chicago.

The study included 235 patients enrolled at Smilow Cancer Hospital at Yale-New Haven who had breast cancer ranging from stage 0 to stage 3.

Participants, who were enrolled in the study, between Oct. 21, 2011, and Nov. 25, 2013, underwent typical partial mastectomies. Surgeons completed the operations as they normally would, to the best of their abilities, and then opened an envelope that told them whether the patient had been randomly selected to either have additional cavity shave margins or not, Chagpar said.

Dr. Anees Chagpar

Dr. Anees Chagpar

“As surgeons, we always do our best to get all the cancer out, with a rim of normal tissue around (it), the first time,” she said. “We’re not always successful. Taking cavity shave margins cut the positive margin rate in half, without compromising the cosmetic outcome or increasing complication rates. That makes a huge difference to patients.”

Patients involved in the study ranged in age from 33 to 94, with a median age of 61. Of the 235 participants, 119 were randomly chosen for the “shave” group, while 116 were in the “no shave” group. Researchers followed up with participants about 22 months later, on average.

Diana Theriault, 37, of Hamden, one of the women in the “shave” group, said the study spared her an additional operation.

“In my case, they would not have gotten negative margins without that shave, so I would have had to go back in to get more surgery,” she said.

Theriault had surgery to remove a lump in her left breast in late June 2013, after being diagnosed with breast cancer earlier that month. The mother of three young children, who was 35 when diagnosed, said battling cancer has been a difficult and overwhelming experience.

“The entire process of having breast cancer, it’s not just emotionally draining for the patient, it’s emotionally draining for the patient’s husband, the patient’s children, the patient’s parents,” she said. “I can’t imagine having had to go back for a second surgery. It would have been devastating.”

“I feel very grateful that I was part of that (study). It seems like such a good, logical thing to do,” she said, noting she didn’t hesitate to enroll in the study when asked by doctors at Smilow. “It sort of seemed like, ‘Why isn’t everybody doing this?’”

A breakdown of the patients in the study showed that 54 had invasive cancer; 45 had ductal carcinoma in situ (DCIS), which is the most common type of non-invasive breast cancer, and 125 had a combination of both.   None of the remaining 11 patients had further disease – two had no residual cancer after chemotherapy, and nine had the “focus of disease” removed completely during a preoperative biopsy, according to the study.

Patients involved in the study will be tracked for five years to gauge the technique’s impact on recurrence rates as well as the impact on cosmetic outcomes, Chagpar said.



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