As the New York Times and other news organizations are reporting, a study published today in the Journal of the American Medical Association, found that nearly one in four women who have a lumpectomy to treat their breast cancer require another surgery to remove additional tissue.

The data come from an observational study of breast surgery performed between 2003 and 2008 at four institutions. The research teams goal was to see if they could use the number of operations a woman undergoes as a potential measure of quality of care. To make this assessment, the researchers looked at how many women required a second surgery because the pathology report showed that there was a not a clean margin. Margin is a term of art used to describe whether there are cancer cells right at the edge of the tissue that has been removed. The idea is that having only normal cells present would indicate that the entire tumor was removed, while the presence of cancer cells would indicate that the surgeon might have cut through the tumor and left cells behind.

The study’s findings imply that some surgeons are not performing high-quality operations. But I don’t think that’s really what this study tells us. To be sure, it’s important to evaluate how well breast surgeons do their work. But I don’t believe that a surgeon’s re-excision rate is a good indicator of their skill or judgment.

One of the big problems in breast surgery is the fact that we don’t have a good map of the anatomy of the breast. Yes, believe it or not, we know more about the molecular biology of the breast cancer cell than we do about the pattern and number of holes there are for milk to emerge from the nipple!

The breast is formed of six to nine ductal systems, which are distributed throughout the breast like branches of a tree. All breast cancer starts in these milk ducts, (lobules which make the milk hang off the ducts like leaves). Like tree branches, the ductal systems are not all the same size or shape, and they are not evenly distributed. You cannot see them on mammography or MRI and they are not visible to the surgeon during surgery.

When a woman has invasive breast cancer, the tumor will present as a lump. These are pretty easy to remove, although the tumor can sometimes have a tail that we can’t feel. Along with an invasive cancer, there will also be ductal carcinoma in situ (DCIS), which are the precancerous cells that are still contained in the ducts.

Although DCIS can be initially diagnosed with microcalcifications on a mammogram, the calcifications do not outline the whole area of involvement. There is no imaging tool that can tell the surgeon how much DCIS is present before the surgery, and a surgeon cannot see it or feel for it during the surgery. We do the best we can, but often leave some behind. These cells can only be seen when the tissue is examined under the microscope later, which is why it can be potentially overlooked.

Secondly, the technique used to identify whether or not a surgeon has obtained clean margins is very crude. It involves taking what in essence is a “wad” of fat (think chicken fat) and painting it with India ink and then taking tangential slices. In reality, it would take 2000 slides to look at every margin of a 2 cm piece of tissue, but we do about 10! In other words, the chance of missing something is high. For this reason, surgeons are leery of assuming all the margins are clean and tend to make decisions based on the pathology instead.

Finally, although it should be the most important, there is the patient choice. Some surgeons may try to do breast conservation, if the patient desires it, only to find that the disease is more extensive than thought and a mastectomy is necessary. In other instances, a women or surgeon may decide prior to surgery that if the surgeon has any questions about whether clean margins have been obtained, they will go straight to mastectomy.

While I am a great believer in outcome measures, I don’t think this area of breast cancer has been sufficiently defined to use these types of measures to determine quality of care. A woman with breast cancer needs to find a surgeon who she is comfortable with, and who she trusts. She should not make that decision based on the surgeon’s re-excision rate, because it is not a good indicator of quality of care and having surgeons and pathologist articulate new guidelines will not improve the situation. What we desperately need is better imaging, which will allow us to map the ductal anatomy and the extent of disease accurately ahead of time, and direct an informed operation rather than what is in essence an exploratory one.

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11 Responses to Breast Cancer Surgery Ignorance of Anatomy, Not a Dearth of Guidelines

  1. I had a lumpectomy and radiation in 2006did.In 2011 had invasive tumor,had to get a masectomy,chemo and herceptin. I feel that i did’nt do enough research to understand how this all happened? To have it come back then find out i have the her 2 gene. This was to over whelming other women my age being diagnosed with breast cancer in a small town.My concern is did he leave tissue behind? :{

  2. d wolf says:

    i had a lumpectomy and re-excision summer 2011 at a large cancer center- this is the first place I finally found an explanation of why lymph glands are checked while in OR the first time but clean margins couldn`t be determined- thank you

  3. Nn says:

    I had a lumpectomy in 2008. I have always wondered if I did the right thing. They said i had clear margins but now I ‘m worried. It sounds like you are saying you should always choose the mastectomy to be safe. I’m thinking of doing it now.

  4. Linda K says:

    I so agree surgeon do not have the right imaging. I had a lupectomy and suposedly the margins were good.I had radiation for 6 weeks. Almost two years later I had an MRI instead of a mammogram and they found ductual carenoma so I had a mastectomy. this article explains better why it came back. They are calling it a failed lumpectomy meaning the cells didn’t go away with raidiation. All I know is I had to have another surgery and now reconstruction when was not informed the high risk of it returning.

  5. Fiona Parker says:

    Tumors are generally hotter than surrounding tissue. Is it possible to detect the outer edges of a tumor using something like infrared detection during surgery?

  6. Vicci Wilkins says:

    My mother had a lumpectomy in 1990 and during this same period my first cousin and my sister-in-law had a mastectomy, they all got their breast cancer the same year. My mother died within two years and my cousin and sister-in-law are thankfully cancer free 19 years later. I have always felt my mother’s chances would have been greater if she had had the mastectomy.

  7. Julia says:

    That’s why I opted for a bilateral mastectomy when lumpectomy margins were close. I had massive DCIS and ILC in that breast and atypical cells in the other. And I skipped rads and chemo. Am happy with my choice which included reconstruction

  8. Julia says:

    Had bilateral mast after close margins on lumpectomy. One breast has massive DCIS & ILC. The other atypical cells. I’m pleased with my choice and avoidance of rad. I sleep better knowing both ticking time bombs are gone! And I got great recon job.

  9. Roz says:

    In 1990 I had a lumpectomy (clear margins) and sentinel node (also clear). I opted to not have radiation. In 2004, I had a recurrence in the same breast. After 3 lumpectomies and unable to get clear margins, I had a mastectomy of my left breast. I had gene testing for the BRCA gene and am negative. Guess it’s just incredibly bad luck! About 8 weeks ago, I had my annual mammo AND ultrasound.
    My oncologist always has me do both. The mammo showed nothing but the ultrasound showed a tumor. I had a lumpectomy and sentinel node biopsy.It was positive. Rather than have radiation, I had a mastectomy. Now my oncologist is suggesting that I take Femara although my oncotype DX shows a low recurrence rate. Not so sure I want to do this. So many side effects.

  10. Pam says:

    I had a lumpectomy in July 2003, a re-excision Aug 2003 due to the margins not being clean. I had chemo followed by radiation. I did not take any medications after that, no tamoxifen or arimidex. I am coming up on 9 years cancer free and I feel great! I would have hated to lose my breasts out of fear.

    Unfortunately, I don’t think a woman can go by what happened to anyone else. I think after talking with her doctor and taking a little time to think over her options, she should do what she feels most comfortable with. For me it was a lumpectomy, for some here it was a mastectomy. The main thing is to survive!

    I am just thankful that there are choices as well as continuing research to make things better for generations to come.

  11. Sandra says:

    I had Bil Mastectomies for Stage IIIA, T3,N2,Mo. Had immediate small implants inserted Aug.2010. Had chemo and radiation finishing 6/28/2011. Am looking for a BREAST RECONSTRUCTION surgeon that is known for doing “Flap” Reconsructions. Any help appreciated. Do NOT like the FEEL or the my LOOK of my implants, mostly the hardness, misshappened discomfort! I live in a small Alabama community. But…Traveling is no problem. For good flap surgery I’d go anywhere in the World! Thank you so much! Sandra

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