Partial Mastectomy Findings at Yale Could Add Value for Patient and Payer

Research conducted at the Yale Cancer Center has found that a procedure known as cavity shave margins or CSM could avoid unnecessary follow-up surgeries and simultaneously save significant costs to the healthcare system.

Through a study published in the New England Journal of Medicine earlier this year, researchers at Yale shared data from a randomized, controlled trial that evaluated the outcomes of routine excision of circumferential CSM versus standard partial mastectomy, including excision of selective margins, in patients undergoing breast-conservation surgery. The randomized study included 235 patients who had been diagnosed with breast cancer following a core-needle biopsy—these were stage 0 to III patients. Patients were randomized into the shave group (CSM) or no-shave group. For patients in the shave group, surgeons resected additional tissue, so that CSM encompassing the entire cavity were removed.

Primary trial endpoint was the rate of positive margins on final pathological testing. Additionally, reexcision rates were recorded as a part of the trial data. These were defined as defined as the proportion of patients who were returned to the operating room for further surgery for margin clearance. Secondary endpoints included the volume of tissue excised and patient-reported cosmesis.

The authors found a clear association between the rate of positive margins and reexcision rates: CSM reduced the rate of positive margins by nearly 50% and more than halved the rate of reexcision when compared with standard partial mastectomy. The analysis showed that patients in the no-shave group were more likely to return to the clinic for a second or third reexcision. Patients in this trial, however, did not view a significant cosmetic difference between the 2 procedures.

As a follow-up on the NEJM study, the authors will now be presenting data at the 2015 Annual San Antonio Breast Cancer Symposium that evaluates time and cost outcomes of CSM. The study found, as would be expected, that CSM increased the time of initial surgery by a median of 10 minutes (76 minutes vs 66 minutes), and also added to the costs of the operating room (OR; $1315 vs $1138), pathology use ($1195 vs $795), and overall costs ($4758 vs $4133). However, the mean cost per patient for additional surgeries was significantly lower in the CSM group ($332) than in the no-shave group ($983), the authors report.

These new data suggest that CSM can reduce patient visits for additional procedures and also improve utilization of surgeon and OR time, which in the long-term can be a significant value-add.

“At a time when healthcare costs are skyrocketing, and patients face significant financial burden with their treatments, it’s increasingly important to look at value in cancer care,” according to first author Anees Chagpar, MD, MPH, associate professor of surgery at Yale School of Medicine and director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven. “We found that taking cavity shave margins resulted in fewer return trips to the operating room at no added cost. Clearly, this is a win all around — for patients, providers, and payers.”