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This Week in JAMA: Feb 1, 2012

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In JAMA this week, a team of US researchers reports on the variability in re-excision rates between hospitals and individual surgeons, following breast conservation surgery. The team conducted an observational study of breast surgery performed between 2003 and 2008, on 2,206 women with invasive breast cancer. Of those patients, 509 had to undergo re-excision, some of them more than once. "Substantial surgeon and institutional variation were observed in re-excision following partial mastectomy in women with invasive breast cancer," the team adds.

In a related JAMA editorial, Memorial Sloan-Kettering Cancer Center's Monica Morrow and the University of Michigan's Steven Katz write that although the treatment of breast cancer is "increasingly multimodal," surgery for patients with solid tumors is almost always necessary. And breast surgery has, until now, largely been excluded from the list of cancer surgeries for which quality control measures have been developed. Re-excision rates after breast cancer surgery could be used as a quality indicator, the authors add, but this is not ideal. "Validity is low because many factors drive the decision to perform margin re-excision, including clinical variables such as the method of pathological margin processing, quality of preoperative imaging, histological tumor type, and patient age," Morrow and Katz write, adding, "Perhaps the most important limitation of using re-excision as a quality measure is the potential consequences of its adoption," like the possibility that patients may pick surgeons solely because they have the ideal re-excision rate. "Although it may be premature to determine quality indicators for the strategies targeting reduction of therapy for favorable patient groups, any proposed quality measures must be evidence based and relevant to the current understanding of breast cancer biology, and the subset of patients for whom the measure applies must be rigorously defined for those measures to be useful to clinicians and beneficial to patients," Morrow and Katz say.

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