Trend Analysis on Reoperation After Lumpectomy for Breast Cancer—Reply

In Reply We concur with Yang et al that our study design cannot definitively address causality, and this limitation was noted in our article. However, a substantial body of evidence strongly suggests that there is a relationship between the margin guideline publication and increased use of less-extensive surgery. Long-term secular trends in the use of breast-conserving surgery documented prior to our study (and publication of the margins guideline) showed decreased use of breast-conserving surgery and a concomitant increased use of mastectomy. Furthermore, a study examining reoperation rates after initial lumpectomy in patients treated prior to publication of the guidelines (2004 through 2010) found only a 2.9% decrease in additional surgery. By contrast, we observed a marked increase in breast-conserving surgery—the result of a substantial decrease in reoperations after lumpectomy. Additionally, we demonstrated that the observed decrease in second surgery after lumpectomy was associated with a high rate of surgeon endorsement of a margin of no ink on tumor. High acceptance rates of margins of no ink on tumor were not observed in earlier studies performed prior to publication of the margin guidelines. Finally, we noted no change in the use of second surgery in the patients with ductal carcinoma in situ, a group not included in the margin guideline, who were sampled during the same period.

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