Opportunities to reduce reoperations and to improve inter-facility profiling after initial breast-conserving surgery for cancer. A report from the NCDB

Abstract Background Repeat operations after breast-conserving surgery (BCS) for cancer have been termed “epidemic.” To aid improvement activities, we sought to identify those National Cancer Data Base (NCDB) characteristics that were associated with reoperations. Methods A retrospective cohort of patients with invasive breast cancer undergoing initial BCS in the NCDB from 2004 to 2015 was identified. Univariate, multivariate, ranking (effect size and R 2 ), and time-trend methods were used to assess associations between patient, facility, tumor, treatment, and calendar-year characteristics with reoperation. Results In 1,226 facilities, 84,462 (16.1%) of 524,594 patients underwent reoperations after BCS [range 0–75%; 10th/90th performance percentiles = 6.6%/25%]. Of 18 factors associated with reoperations, facility ID was the highest ranked. Its estimated impact on the odds of reoperation were more than 10 times greater than any other factor considered, followed by tumor size, neo-adjuvant chemotherapy receipt, patient age, cancer histology, and nodal status. Reoperations after the year of the SSO-ASTRO margin guideline declined significantly compared with prior years. Significant inter-facility reoperation variability persisted after risk adjustment for more than a dozen distinct patient, facility, tumor and treatment characteristics. Conclusion In the NCDB, significant inter-facility variability exists regardless of case volume, case mix, and risk adjustment. There were fewer reoperations after the SSO-ASTRO guideline. An endorsed target rate of 10% was achieved by only 1 in 4 facilities. The most impactful determinant of reoperation was the facility itself. Thus, all stakeholders should consider participation in improvement activities. Such activities will benefit from risk-adjusted profiling; the relevant adjustors were identified.