They also found that being more aggressive about tissue removal did not affect the way patients regarded the cosmetic outcome.
Decades of research have shown that the cavity shave margin technique is not expected to increase survival, because going to the extreme of removing the whole breast doesn’t help cancer patients live longer compared to removing part of it with a lumpectomy and using follow-up treatment with chemotherapy and radiation.
But cutting the odds that patient will need more surgery because the surgeon didn’t catch all the cancer cell fist time does not make a difference in terms of patient’s angst and the emotional impact of returning to the operation room.
The study attempted to resolve the controversy over whether the surgeons should remove extra bit more tissue when they are removing a breast tumor.
Dr Anees Chagpar of the Yale University School of Medicine in New Haven and the lead author of the study said, “Now that we have data from a Level 1 randomized controlled trial, many surgeons are changing their practice,” she said. “It’s really hard to ignore Level 1 evidence that shows you can cut the reoperation rate in half without changing the cosmetic outcome or increasing complications. That’s kind of a no-brainer.”
20 to 40 percent of the patients need to have second operation because a microscopic examination of the removed tissue reveals cancer cells where the surgery cut, a problem doctors refer to as positive margins.
Four Yale surgeons did the tumor removal for the study, using their judgment to decide how much tissue to take around the tumor.
Chagpar said, “We told the surgeons, do your best operation and once you’re happy and ready to close, you’re going to open an envelope and be instructed to close, or take a little bit more tissue all the way around.”
Among the 119 treated with shave margins, the rate of positive margins was 19 percent, versus the 34 percent among the 116 patients in the non shave group, where no extra tissue was taken.
In addition, the likelihood of needing a second surgery to clear out those missed cancer cells also lower 10 percent in the shave margin groups versus 21 percent in the control group.
The decision whether to follow up operation was left to the discretion of the surgeons.
In both groups, 37 percent rated the cosmetic outcome of their surgery as excellent, with 50 percent in shave group and 54 percent in the non shave group saying their outcome was good.
Researchers said, “We found that the perception of cosmetic outcome was equivalent in the two groups . . . despite the fact that the shave group had more tissue excised.”
Overall, among the women who had a little extra breast tissue removed, 12 percent had evidence of cancer cells in that extra tissue.
Chagpar said, from reducing the need from follow-up surgery, “The importance of these findings is still uncertain” because most of the women who didn’t have the extra tissue removed would probably have done fine with established therapy.
Chagpar said, “It may be that there’s no impact and that in the modern era, with the existing treatments after breast-conserving surgery, it may be that the disease found in the shaved margins may make no difference whatsoever. This is a question we may be able to answer as we follow these patients long-term.”