Repeated Breast-Conserving Surgeries Come With Significant Complications and Costs Interview with:

Dr. Lisa K. Jacobs MD Johns Hopkins School of Medicine Baltimore, Maryland

Dr. Jacobs

Dr. Lisa K. Jacobs MD
Johns Hopkins School of Medicine
Baltimore, Maryland What is the background for this study? What are the main findings?

Response: Breast preservation is the preferred treatment for many women diagnosed with breast cancer.  The most common question that a patient will ask after the surgery is, “Did you get it all?” In the ideal case, this is accomplished in a single outpatient surgery with very good cosmetic results.  In our study, Beyond the Margins-Economic Costs and Complications Associated with Repeated Breast-Conserving Surgeries we evaluated the detrimental effects of an unsuccessful initial surgery due to positive surgical margins. Using private insurance claims data, we found that 16% of patients planning breast preservation required a second breast-conserving surgery and an additional 7% converted to mastectomy.  Of those patients that required additional surgery there was a 56% ($16,072) increase in cost and a 48% increase in complications.  Those complications include infection, hematoma, seroma, and fat necrosis.  This study demonstrates that repeated surgery has not only cosmetic consequences, but also has financial implications and increased risk. What should clinicians and patients take away from your report?

Response: Efforts to reduce the number of repeated surgeries have the potential to decrease the cost of breast preservations significantly.  There are a variety of ways that surgeons have attempted to reduce the number of repeated surgeries due to positive margins, but none of these have shown uniform success and none have been adopted nationally.  There is ongoing research into new technologies that help to reduce the positive margin rate and therefore the repeated surgery rate without compromising the patient’s care.  We also expect that guidelines defining adequate margins will help to reduce the number of repeated surgeries. What recommendations do you have for future research as a result of this study?

Response: There are a number of investigators evaluating ways to reduce the positive margin rate.

The most important considerations are (1) is the intervention possible in the operating room in real time and (2) what percentage of patients will avoid a repeat surgery.  Importantly, the evaluation of any such technique must include clinical outcome data; using sensitivity and specificity on a margin-by-margin basis does not directly address the concerns identified in our paper.

A patient must return to the OR for even a single positive margin, so any technique must correctly identify all positive margins to prevent a re-intervention.  The number of repeated surgeries is the most important outcome to patients and the one that incurs the additional costs and complications. Is there anything else you would like to add?

Response: I am the principal investigator of a study to evaluate a margin assessment device and had joint NIH grant funding from Diagnostic Photonics to study the device. Thank you for your contribution to the community.


Metcalfe LN, Zysk AM, Yemul KS, Jacobs LK, Oker EE, Underwood HR, Thompson AM. Beyond the Margins—Economic Costs and Complications Associated With Repeated Breast-Conserving Surgeries. JAMA Surg. Published online August 02, 2017. doi:10.1001/jamasurg.2017.2661


Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.


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Last Updated on August 2, 2017 by Marie Benz MD FAAD