The University of Michigan Comprehensive Cancer Center has managed to reduce the number of repeat surgeries drastically by having an on-site pathologist in the operating room, who examines the tumors and lymph nodes immediately after their removal and feeds the results back to the waiting operating staff, who can continue any additional surgery immediately if necessary.
The approach, featured in the American Journal of Surgery, succeeded in reducing the number of repeat surgeries by 64%, which means one in every 10 women did not have to undergo a second surgery.
The service was introduced approximately 2 years ago at the U-Ms East Ann Arbor Ambulatory Surgery Center, which caters for the majority of outpatients' breast cancer surgeries. To assess the efficiency of this approach, researchers assessed 271 patients who received treatment eight months before and 278 patients who were treated eight months after the program was implemented.
Leading author Michael S. Sabel, M.D., associate professor of surgery at the U-M Medical School comments:
"The frequent need for second surgeries among patients undergoing breast cancer surgery represents a tremendous burden for patients. Beyond the inconvenience and additional time away from work, additional surgeries can result in worse cosmetic outcomes and increased complication rates. Our experience shows that offering on-site pathology consultation has a substantial impact on quality of care."
The two key reasons for patients requiring repeat surgery are usually to remove extra tissue if cancer cells are in too close proximity to the removed tissue, and in some instances, to remove additional lymph nodes if initial lymph node biopsy has tested positive for cancer.
25% of patients required repeat surgery prior to implementing an on-site pathologist, compared with only 11% afterwards. 93% of patients with cancerous lymph nodes were able to avoid repeat surgery after the introduction of on-site pathology.
Study findings showed that aside from decreasing the numbers of repeat surgeries, assessing the margins in the OR meant that more women were able to avoid a mastectomy. According to the researchers, women with positive margins in need of repeat surgery are more likely to opt for a mastectomy, due to fear their cancer may return or that they will require a third operation.
Including an on-site pathology lab in the OR requires a different approach for preserving and undertaking cell biopsies, called a frozen section analysis. Once completed, the pathologists perform standard biopsy tests using traditional methods. Results for both types of analyses proved consistent. A few academic medical centers across the country currently offer on-site pathology using frozen tissue sections.
"In large part, routine intra-operative analysis of lumpectomy margins is rare because of logistical issues, especially as breast surgery is more commonly performed at outpatient surgical centers."
To include on-site pathology requires overcoming obstacles, such as transporting the tissue samples, building a pathology facility, and staffing it appropriately at an offsite surgical center.
"Despite these obstacles, we found that not only is this beneficial for our patients, but it reduced the costs of caring for patients with breast cancer. Establishing an intra-operative pathology consultation service is feasible, highly efficient and extremely beneficial to patients, surgeons and reducing the costs of cancer care."
The researchers also thought of introducing new guidelines that suggest fewer women need to have their lymph nodes removed if the sentinel lymph node biopsy is positive. They accounted for this reduction and still found intra-operative analysis to be highly cost-effective.
Written by Petra Rattue