Norma J. Vinger Center for Breast Cancer, Gundersen Health System, 1900 South Ave, La Crosse, WI, 54601, USA; Department of Medical Research, Gundersen Medical Foundation, 1900 South Ave, La Crosse, WI, 54601, USA.
University of Wisconsin - La Crosse, 1725 State Street, La Crosse, WI, 54601, USA.
Eur J Surg Oncol. 2019 Nov;45(11):2026-2036. doi: 10.1016/j.ejso.2019.07.002. Epub 2019 Jul 3.
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.
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 R), and time-trend methods were used to assess associations between patient, facility, tumor, treatment, and calendar-year characteristics with reoperation.
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.
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.
乳腺癌保乳手术后（BCS）的再次手术已被称为“流行”。为了帮助改进活动，我们试图确定与再次手术相关的国家癌症数据库（NCDB）特征。
从 2004 年至 2015 年，在 NCDB 中确定了接受初始 BCS 的浸润性乳腺癌患者的回顾性队列。使用单变量、多变量、排名（效应大小和 R）和时间趋势方法评估患者、设施、肿瘤、治疗和日历年份特征与再次手术之间的关联。
在 1226 家机构中，524594 例患者中有 84462 例（16.1%）在 BCS 后接受了再次手术[范围为 0-75%；第 10/90 百分位值=6.6%/25%]。在与再次手术相关的 18 个因素中，设施 ID 是排名最高的。其对再次手术可能性的估计影响是其他任何考虑因素的 10 倍以上，其次是肿瘤大小、新辅助化疗、患者年龄、癌症组织学和淋巴结状态。与前几年相比，在 SSO-ASTRO 切缘指南发布后的年份，再次手术的数量明显下降。在对十多个不同的患者、设施、肿瘤和治疗特征进行风险调整后，仍然存在显著的设施间再次手术变异性。
在 NCDB 中，无论病例数量、病例组合和风险调整如何，都存在显著的设施间变异性。在 SSO-ASTRO 指南发布后，再次手术的数量减少。只有 1/4 的设施达到了 10%的目标率。再次手术的最具影响力的决定因素是设施本身。因此，所有利益相关者都应考虑参与改进活动。此类活动将受益于风险调整分析；已确定了相关调整因素。
