We Are Doing More, Are We Getting Any Better?an Analysis Of The American College Of Surgeons National Surgical Quality Improvement Program (acs Nsqip) Database
Mimi Rosealie Borrelli, MBBS, MSc, BSc, Thor Stead, MSc, Victor King, MD, Benjamin Christian, MD, Jennifer Gass, MD, Paul Liu, MD, Erik Hoy, MD.
Brown, Providence, RI, USA.
PURPOSE: Lumpectomy for breast cancer has a risk of contour deformity particularly with larger volume resection or smaller native breast size.Combining tumor resection with principles of volume displacement and volume replacement, has been described as oncologically safe and is associated with improved aesthetic outcomes and greater patient satisfaction. Consequently, use of oncoplastic surgery (OPS) has been increasingly adopted over the past decade. We queried a national database to provide a current comparison of the outcomes of OPS versus traditional partial mastectomy.
METHODS: Data on all female patients with breast cancer who underwent OPS or traditional lumpectomy from 2005-2019 was retrieved from The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. OPS patients were defined as patients with concomitant current procedural terminology (CPT) codes identifying soft tissue transfer. T- and chi-squared tests were used to compare demographics and postoperative outcomes between OPS and traditional lumpectomy patients, and multivariable logistic analyses were performed to identify factors predictive of postoperative morbidity. The false discovery rate (FDR) was controlled for at the 5% level to diminish confounding effects and odds ratios were adjusted for comorbidities.
RESULTS: Data on 346,915 patients were analyzed; 38% (n=130,270) had oncoplastic surgery. The number of OPS increased from 244 cases in 2005/2006 to 20,410 cases in 2019. Compared with the lumpectomy group, OPS patients were younger, non-smokers, were less likely to have COPD or diabetes, and were more likely to have received neoadjuvant chemotherapy. Radiation did not differ between groups. OPS patients had a longer median operative times but shorter hospital stays; specifically, OPS operations lasted 61 minutes longer than lumpectomies (95%CI: 60.1-62.2 min, p<0.001) and OPS patients were discharged 0.67 days earlier from hospital (95%CI: 0.65-0.69, p<0.001). The most significant independent predictor of morbidity probability was OPS (controlling for diabetes, radiation, chemotherapy, COPD, smoking status); morbidity was 10.7% lower in patients who had OPS (95%CI: 10.3-11.0, p<0.001). Despite OPS involving longer procedures with greater tissue manipulation, OPS patients were 52.4% less likely to suffer wound dehiscence (p<0.001) and 21% less likely to suffer a wound infection (p<0.001). Rates of re-operation, readmission, sepsis, and wound closure did not significantly differ between patient groups.
CONCLUSION: This national data analysis revealed OPS is increasingly performed in the US. OPS does not increase risk for complications, and thus represents safe and effective surgery for women with breast cancer who are suitable candidates. In fact, OPS was associated with reduced morbidity and fewer complications, in contrast to our local experience and single-center studies. While techniques such as careful distribution of tension, reduction of dead-space, possible use of drains, and delicate handling of soft tissue may help improve patient outcomes, further exploring this discrepancy will be a focus of our future investigation. Plastic surgeons look to remain a definitive part of breast reconstruction, and oncoplastic surgery can either be viewed as a threat or an opportunity. Our suggest that we can help our colleagues and remain integral to the attainment of optimal outcomes for all breast cancer patients.
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