Opportunities to reduce reoperations and to improve inter-facility profiling after initial breast-conserving surgery for cancer. A report from the NCDB

Abstract

Background: Repeat operations after breast-conserving surgery (BCS) for cancer have been termed "epidemic." To aid improvement activities, we sought to identify those National Cancer Data Base (NCDB) characteristics that were associated with reoperations.

Methods: A retrospective cohort of patients with invasive breast cancer undergoing initial BCS in the NCDB from 2004 to 2015 were identified. Univariate, multivariate, ranking (effect size and R²), and time-trend methods were used to assess associations between patient, facility, tumor, treatment, and calendar-year characteristics with reoperation.

Results: In 1226 facilities, 84,462 (16.1%) of 524,594 patients underwent reoperations after BCS [range 0-75%; 10th/90th performance percentiles = 6.6%/25%]. Of 18 factors associated with reoperations, facility ID was the highest-ranked. Its estimated impact on the odds of reoperation was more than 10 times greater than any other factor considered, followed by tumor size, neo-adjuvant chemotherapy receipt, patient age, cancer histology, and nodal status. Reoperations after the year of the SSO-ASTRO margin guideline declined significantly compared with prior years. Significant inter-facility reoperation variability persisted after risk adjustment for more than a dozen distinct patient, facility, tumor, and treatment characteristics.

Conclusion: In the NCDB, significant inter-facility variability exists regardless of case volume, case mix, and risk adjustment. There were fewer reoperations after the SSO-ASTRO guideline. An endorsed target rate of 10% was achieved by only 1 in 4 facilities. The most impactful determinant of reoperation was the facility itself. Thus, all stakeholders should consider participation in improvement activities. Such activities will benefit from risk-adjusted profiling; the relevant adjustors were identified.

Keywords: Breast cancer; Breast-conserving surgery; Lumpectomy; National cancer data base (NCDB); Reoperations; Society of surgical oncology-American society for radiation oncology (SSO-ASTRO) margin guideline.