Whither surgical quality assurance of breast cancer surgery (surgical margins and local recurrence) after paterson

Breast Cancer Research and Treatment, Jul 2017

Purpose The Kennedy report into the actions of the disgraced Breast Surgeon, Paterson focussed on issues of informed consent for mastectomy, management of surgical margins and raised concerns about local recurrence rates and the increasing emphasis on cosmesis after mastectomy for breast cancer. This article assesses whether Kennedy’s recommendations apply to the UK as a whole and how to address these issues. New GMC advice on consent and newer nonevidenced innovations in immediate reconstruction have altered the level of informed consent required. Patients deserve a better understanding of the issues of oncological versus cosmetic outcomes on which to base their decisions. Involvement of the whole multidisciplinary team including Oncologists is necessary in surgical planning. Failure to obtain clear microscopic margins at mastectomy leads to an increased local recurrence, yet has received little attention in the UK. Whereas, other countries have used surgical quality assurance audits to reduce local recurrence; local recurrence rates are not available and the extent of variation across the UK in margin involvement after surgery, its management and relationship to local recurrence needs auditing prospectively to reduce unnecessary morbidity. To reassure public, patients and the NHS management, an accreditation system with more rigour than NHSBSP QA and peer review is now required. Resource and efforts to support its introduction will be necessary from the Royal College of Surgeons and the Association of Breast Surgeons. New innovations require careful evaluation before their backdoor introduction to the NHS. Private Hospitals need to have the same standards imposed.

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Whither surgical quality assurance of breast cancer surgery (surgical margins and local recurrence) after paterson

Whither surgical quality assurance of breast cancer surgery (surgical margins and local recurrence) after paterson N. J. Bundred 0 1 2 3 J. Thomas 0 1 2 3 J. M. J. Dixon 0 1 2 3 0 Western General Hospital , Edinburgh EH4 2 XU , UK 1 Department of Surgery, Education and Research Centre, University Hospital of South Manchester , 2nd Floor, Southmoor Road, Manchester M23 9LT , UK 2 & N. J. Bundred 3 Edinburgh Breast Unit, Western General Hospital , Edinburgh EH4 2XU , UK Purpose The Kennedy report into the actions of the disgraced Breast Surgeon, Paterson focussed on issues of informed consent for mastectomy, management of surgical margins and raised concerns about local recurrence rates and the increasing emphasis on cosmesis after mastectomy for breast cancer. This article assesses whether Kennedy's recommendations apply to the UK as a whole and how to address these issues. New GMC advice on consent and newer nonevidenced innovations in immediate reconstruction have altered the level of informed consent required. Patients deserve a better understanding of the issues of oncological versus cosmetic outcomes on which to base their decisions. Involvement of the whole multidisciplinary team including Oncologists is necessary in surgical planning. Failure to obtain clear microscopic margins at mastectomy leads to an increased local recurrence, yet has received little attention in the UK. Whereas, other countries have used surgical quality assurance audits to reduce local recurrence; local recurrence rates are not available and the extent of variation across the UK in margin involvement after surgery, its management and relationship to local recurrence needs auditing prospectively to reduce unnecessary morbidity. To reassure public, patients and the NHS management, an accreditation system with more rigour than NHSBSP QA and peer review is now required. Resource and efforts to support its introduction will be necessary from the Royal College of Surgeons and the Association of Breast Surgeons. New innovations require careful evaluation before their backdoor introduction to the NHS. Private Hospitals need to have the same standards imposed. Breast Cancer; Local recurrence; Mastectomy; Involved margins - The UK Breast Surgeon, Ian Paterson received a 15 year jail sentence last month after being convicted of intentionally wounding his patients in Private hospitals. He misled vulnerable concerned patients worried about having a breast cancer and persuaded them to undergo unnecessary major surgical procedures rather than reassuring them they had no evidence of cancer. The Kennedy report [ 1 ] into the actions of Paterson in NHS practice focussed on several themes but crucially questioned issues of informed consent, management of surgical margins and raised concerns about local recurrence rates and his emphasis on cosmesis after mastectomy for breast cancer. The report noted a premise widely accepted that ‘‘if you cut a cancer out and it is present at the edges (of the cut) there is an increased risk that it will come back at the edge’’. Kennedy reported that the West Midlands had an overall 1.4% local recurrence rate following mastectomy, but Paterson had an overall 3% local recurrence at 5 years, although after Cleavage Sparing Mastectomy (CSM) or following mastectomy and immediate reconstruction, it was 5.7% after 5 years rising to 9% by 10 years. Paterson’s high rate of local recurrence was explained by Kennedy as due to his nonevidence based ‘‘CSM’’ technique which left breast tissue behind and produced a high microscopic margin involvement after mastectomy, despite oncologists mitigating risk with adjuvant radiotherapy [ 1 ]. Paterson’s prioritisation of cosmesis over complete cancer removal, left margins involved with cancer in 10-37% of cases undergoing CSM and resulted in a 9–18% local recurrence rate at 5 years after Mastectomy and Reconstruction [ 1 ]. Following local recurrence in the breast there is a 1 in 4 risk of dying from cancer [ 2 ]. Internationally, local recurrence rates (LRR) after mastectomy have fallen from 20% in the 1990s to 3% or less, in part due to the increased use of Adjuvant Systemic Therapy. Local recurrence varies with Tumour Phenotype (higher rate in Oestrogen Receptor Negative and HER2 positive cancers), node status and microscopic margin involvement (not type of Mastectomy). The only factor the Surgeon can influence is Margin Status [ 2, 3 ]. After Mastectomy for DCIS (when adjuvant therapy is not indicated), Fitzsullivan [ 4 ] reported on 810 patients with DCIS, of whom 66% had Immediate Breast Reconstruction with an overall LRR of 1% at 5 years. Intraoperative margin assessment by Frozen Section reduced the margin involvement rate from 14% to a final rate of 7.3%. Margin involvement was associated with a significantly higher 5% local recurrence rate (which was not affected by post-mastectomy radiotherapy), and was the only independent predictor of local recurrenc (...truncated)


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N. J. Bundred, J. Thomas, J. M. J. Dixon. Whither surgical quality assurance of breast cancer surgery (surgical margins and local recurrence) after paterson, Breast Cancer Research and Treatment, 2017, pp. 1-3, DOI: 10.1007/s10549-017-4369-3