Variability in Surgical Quality among Surgeons in Breast Cancer Surgery

Introduction: Quality assurance is an essential aspect of cancer care. Assessment of surgical quality in breast cancer is still evolving. Variability in surgical care among surgeons has been well documented in literature and we sought to investigate such variation between two groups of surgeons referring patients to our oncology center. Methods: A prospective review of patient records of all breast cancer referrals to our department was made. Two groups were identified and segregated based on the performance of mastectomy by a general surgeon (GS) or by a surgical oncologist (SO). Patients treated with modified radical mastectomy for clinical stages 1 - 3 were included for the study. Patient demographic data and disease related information were collected in addition to thorough evaluation of the surgical pathology report. Margin positivity, mean nodal harvest, nodal ratio, inadequate axillary clearance, revision surgery and the use of radiotherapy for inadequate nodal dissection were the parameters evaluated in the study. Results: A total of 142 patient records were evaluated 72 designated as group 1 (general surgeons) and 70 as group 2 (surgical oncologist). The median age was 52 years and both groups were evenly balanced for age, laterality of breast lesion, histological type and grade. The mean nodal harvest was 8 vs. 14 nodes, and significant differences were observed in favor of surgical oncology group in margin positivity (P = 0.01), inadequate axillary clearance (P = 0.0001), and requirement of radiotherapy for inadequate axillary clearance (P = 0.0001) but not for revision surgery (P = 0.134). An assessment of prognostic factors revealed both groups to be well balanced for confounding factors. Conclusion: Breast cancer surgical care is amenable to quality assessment. Variation in oncological clearance exists between surgical oncologist and non-oncology trained surgeons involved in mastectomy for breast cancer. An assessment of factors leading to the observed quality differences may be addressed in future trials to ensure optimal breast cancer care.