The effect of dedicated breast surgeons on outcomes in breast cancer: do numbers matter?

Abstract

Improved clinical outcomes as a function of larger case volume likely reflects both the technical competence of the surgeon and his/her participation in a multidisciplinary care team. Increased case numbers are associated with larger percentages of margin-free excisions, smaller volumes of resection and decreased surgical complications for patients undergoing skin-sparing mastectomy with preservation of the nipple-areolar complex. Increased case numbers are also associated with the patient’s receipt of radiotherapy and systemic therapy.

Zusammenfassung

Verbesserte klinische Ergebnisse in Abhängigkeit höherer Fallzahlen spiegeln wahrscheinlich sowohl die technische Kompetenz des Chirurgen, als auch dessen Mitgliedschaft in einem multidisziplinären Behandlungsteam wieder. Die erhöhten Fallzahlen werden mit höheren Prozentanteilen von randfreien Exzisionen, kleineren Resektionsvolumina und rückläufigen Operationskomplikationen bei Patienten, die sich einer hautsparenden Mastektomie/Brustamputation unter Beibehaltung des Mamillenareolenkomplexes unterziehen, zusammengebracht. Die erhöhten Fallzahlen stehen dabei auch mit der Aufnahme von Strahlentherapie und systemischer Therapie durch die Patienten in Verbindung.

Key words

breast cancer - case numbers - margins - recurrence - survival - sentinel lymph node - cosmesis - skin-sparring mastectomy - multidisciplinary

Schlüsselwörter

Brustkrebs - Fallzahlen - Resektionsränder - Rückfall - Überleben - Wächterlymphknoten - Kosmetik - hautsparende Mastektomie - Multidisziplinarität

• Literature

• 1 Early Breast Cancer Trialists' Collaborative G. Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005; 365: 1687-1717
• 2 Dominici LS, Mittendorf EA, Wang X et al. Implications of constructed biologic subtype and its relationship to locoregional recurrence following mastectomy. Breast Cancer Res 2012; 14: R82
• 3 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: 1507-1515
• 4 Wazer DE, Schmidt-Ullrich RK, Ruthazer R et al. Factors determining outcome for breast-conserving irradiation with margin-directed dose escalation to the tumor bed. Int J Radiat Oncol Biol Phys 1998; 40: 851-858
• 5 Mansfield CM, Komarnicky LT, Schwartz GF et al. Ten-year results in 1070 patients with stages I and II breast cancer treated by conservative surgery and radiation therapy. Cancer 1995; 75: 2328-2336
• 6 Wockel A, Wolters R, Wiegel T et al. The impact of adjuvant radiotherapy on the survival of primary breast cancer patients: a retrospective multicenter cohort study of 8935 subjects. Ann Oncol 2014; 25: 628-632
• 7 Meric F, Mirza NQ, Vlastos G et al. Positive surgical margins and ipsilateral breast tumor recurrence predict disease-specific survival after breast-conserving therapy. Cancer 2003; 97: 926-933
• 8 Anderson SJ, Wapnir I, Dignam JJ et al. Prognosis after ipsilateral breast tumor recurrence and locoregional recurrences in patients treated by breast-conserving therapy in five National Surgical Adjuvant Breast and Bowel Project protocols of node-negative breast cancer. J Clin Oncol 2009; 27: 2466-2473
• 9 Overgaard M, Hansen PS, Overgaard J et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial. N Engl J Med 1997; 337: 949-955
• 10 Ragaz J, Jackson SM, Le N et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997; 337: 956-962
• 11 Overgaard M, Jensen MB, Overgaard J et al. Postoperative radiotherapy in high-risk postmenopausal breast-cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999; 353: 1641-1648
• 12 Darby S, McGale P. Early Breast Cancer Trialists' Collaborative G, et al. Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Lancet 2011; 378: 1707-1716
• 13 Whelan TJ, Julian J, Wright J et al. Does locoregional radiation therapy improve survival in breast cancer? A meta-analysis. J Clin Oncol 2000; 18: 1220-1229
• 14 Winkfield KM, Harris JR. Effective local therapy and long-term survival in breast cancer. Oncology (Williston Park) 2009; 23: 669-675
• 15 Kyndi M, Sorensen FB, Knudsen H et al. Estrogen receptor, progesterone receptor, HER-2, and response to postmastectomy radiotherapy in high-risk breast cancer: the Danish Breast Cancer Cooperative Group. J Clin Oncol 2008; 26: 1419-1426
• 16 Rabinovitch R, Kavanagh B. Double Helix of breast cancer therapy: intertwining the Halsted and Fisher hypotheses. J Clin Oncol 2009; 27: 2422-2423
• 17 Kingsmore D, Hole D, Gillis C. Why does specialist treatment of breast cancer improve survival? The role of surgical management. Br J Cancer 2004; 90: 1920-1925
• 18 Skinner KA, Helsper JT, Deapen D et al. Breast cancer: do specialists make a difference?. Ann Surg Oncol 2003; 10: 606-615
• 19 Sainsbury R, Haward B, Rider L et al. Influence of clinician workload and patterns of treatment on survival from breast cancer. Lancet 1995; 345: 1265-1270
• 20 Baum M. Specialist surgeons and survival in breast cancer. Large differences in survival are not explained. BMJ 1996; 312: 1155
• 21 Tafra L. The learning curve and sentinel node biopsy. Am J Surg 2001; 182: 347-350
• 22 Kuehn T, Vogl FD, Helms G et al. Sentinel-node biopsy for axillary staging in breast cancer: results from a large prospective German multi-institutional trial. Eur J Surg Oncol 2004; 30: 252-259
• 23 Mamounas EP, Brown A, Anderson S et al. Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer: results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol 2005; 23: 2694-2702
• 24 Staradub VL, Rademaker AW, Morrow M. Factors influencing outcomes for breast conservation therapy of mammographically detected malignancies. J Am Coll Surg 2003; 196: 518-524
• 25 Wang F, Peled AW, Garwood E et al. Total skin-sparing mastectomy and immediate breast reconstruction: an evolution of technique and assessment of outcomes. Ann Surg Oncol 2014; 21: 3223-3230
• 26 Kesson EM, Allardice GM, George WD et al. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ 2012; 344: e2718
• 27 Houssami N, Sainsbury R. Breast cancer. multidisciplinary care and clinical outcomes. Eur J Cancer 2006; 42: 2480-2491
• 28 Ingram DM, McEvoy SP, Byrne MJ et al. Surgical caseload and outcomes for women with invasive breast cancer treated in Western Australia. Breast 2005; 14: 11-17
• 29 Golledge J, Wiggins JE, Callam MJ. Effect of surgical subspecialization on breast cancer outcome. Br J Surg 2000; 87: 1420-1425
• 30 Coates AS, Winer EP, Goldhirsch A et al. Tailoring therapies-improving the management of early breast cancer: St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2015. Ann Oncol 2015; 26: 1533-1546
• 31 Kowalski C, Ferencz J, Brucker SY et al. Quality of care in breast cancer centers: results of benchmarking by the German Cancer Society and German Society for Breast Diseases. Breast 2015; 24: 118-123