National Margins Audit
A study looking at excision margins and outcomes in DCIS and invasive breast cancer
The recommended margin width following breast conservation therapy in the UK is not clearly defined and considerable variation in accepted margin diameter is seen in units across the country.
In the NICE guidelines for early and locally advanced breast cancer (NICE, 2009), the margin clearance for DCIS is defined at 2mm but a recommendation for the minimum margin width for invasive disease is not made. The London Cancer Alliance Breast Cancer guidelines from October 2013 state that radial margins must comply with the local MDT standard. These guidelines also state that there are no data to support a specific margin of excision but it should be at least greater or equal to 1mm (LCA, 2013).
Why do we need a national audit for margins and breast cancer surgery?
Current practice in the UK is variable. In the light of the recent metanalysis on margins and the adoption of “clear at the inked margin” as the standard by the Society of Surgical Oncology and American Society for Radiation Oncology in 2014, even local guidelines including that of the LCA (equal or greater than 1mm) can be considered out of date.
Excessively wide margins may have a detrimental impact on patient outcome. There may be a cosmetic penalty which may be further impacted by radiotherapy. Further procedures such at lipomodelling may be required to address this at additional cost to the NHS. Patients undergoing margin re-excision may suffer worsening cosmesis (when previously considered acceptable) and are placed at an increased risk wound infection, chronic pain, seroma, poor scarring and anaesthetic complications. The process of margin re-excision raises patient anxiety, and places additional burden on already busy theatre lists and may delay the onset of adjuvant treatment. Additional costs are associated with a second (or third) anaesthetic, a hospital bed and further histological analysis.
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