Leading Breast Surgeon Reviews Current Treatment Environment and How to Address High Re-Excision Rates

Dr. Molly Sebastian had very personal reasons for becoming a breast surgeon. “My mom went through breast cancer treatment while I was in physician training and this was a big contributor to why I choose this specialty,” she shared. “My mother’s surgeon ended up becoming my partner for 8 years and that relationship shaped a lot of what I do today in my approach to care for patients. I feel like it’s a real privilege to help people out and have this kind of practice. And I also feel that 2017 is a great time to be a breast surgeon.“

The surgeon shared why she is so optimistic about the future of breast cancer surgery, including factors such as recent improvements in safely sparing women from axillary lymph nodes dissection, and the ability to better target chemo and other therapies in a way that makes major advances in long-term care outcomes. It’s the high level of interest and ongoing research in the subject that she believes makes the difference as she stated, “The way I perform surgery now is better than 10 years ago, and what I do 10 years from now will be better than today.”

Challenges remaining

But Dr. Sebastian pointed out that difficulties still remain. She feels that patient communication can be an issue, and that keeping a patient informed about their health is essential to developing the right partnership to both prevent and treat diseases such as breast cancer. “In many cases, patients that are at a high risk for developing breast cancer are not being informed about the advantages of genetic testing to identify and then mitigate their risk,” she stated. “But fortunately, the Internet has created a sea change in medicine. Patients with no background in biology are coming in with informed questions and they want to hear how you’re going to help them. It challenges us to explain things clearly to them and address the issues that are identified.”

Another primary challenge is determining the cause of the currently high rates of reexcision. “I think it’s clear from articles in the New England Journal of Medicine and others over the last 2 years that incidents of margin reexcision are too high in the U.S.,” stated Dr. Sebastian. “Studies are showing reexcision rates of 30-40%, and that’s really shocking. In some cases, our surgical communities are calling this an epidemic. It’s definitely a call to action for every breast surgeon to do something to protect their patients from these high rates.”

“Often, reexcision is considered a minor surgery, but it is a procedure with significant cost and it can be very disconcerting for some patients,” she continued. “Patients read articles in the media and are aware of these high reexcision rates. They read where surgeons are not doing enough to protect them from a second or possible third operation, and it becomes a direct patient concern. But it can also be very reassuring if a patient hears that a surgeon has a strategy to protect them from this.”

Strategies to shrink high reexcision rates

Dr. Sebastian feels there are many avenues to bring down reexcision rates. “We’re lucky in breast cancer care that in many cases with a small lesion, there is more than one way to treat it with medically equivalent outcomes,” she explained. “With a mastectomy, or a partial mastectomy with radiation, the 40-yr data shows that the outcomes are the same. If we’re doing our jobs correctly, we need to be very carefully in counseling patients about the pros and cons of each treatment option.”

One option is a new tool to determine the proper margins during surgery: MarginProbe.

MarginProbe significantly cuts reexcision rates

Dr. Sebastian outlined her own experience with MarginProbe. “In my practice, we were early adopters of MarginProbe and have been using it for over 5 years routinely for every lumpectomy,” she explained. “Virginia Hospital Center was one of the first 6 hospitals to purchase MarginProbe in the country. They decided to flip the beta testing and randomize who would get treated using the probe. At first, surgeons that landed on this randomized selection were disappointed because they did not want to add 5-10 minutes to their technique, but after using it regularly for 5-6 years, I can say for myself that there is no question it has made my practice much more efficient.  This happens by eliminating return trips to the OR for 60% of my partial mastectomy patients—that’s huge.”

Over the years, Dr. Sebastian has complied significant data on her success using MarginProbe. “In 2014, I made a presentation at the American Society of Clinical Oncology (ASCO) with 4 other physicians,” she shared. “We combined our before and after data using MarginProbe. This was a sample of 50-100 patients, and my reexcision rate was one of the highest at around 25%. Among the 4 surgeons, the average reduction in reexcision rate after using MarginProbe was 62%. My own rate dropped to around 10%, and it has only gotten better as my experience with MarginProbe increased. My reexcision rate during our last audit is in the single digits—5-7%. While there is more than one way to solve the reexcision epidemic, in our practice we’ve had really nice results with MarginProbe.”

“MarginProbe provides information in the operating room about whether a margin is positive or negative and that is extremely valuable,” she continued. “Surgeries are a very technique-centered discipline. MarginProbe is one of the tools that adds significant value-add to that technique. The more MarginProbe readings I take, the more information I get. It’s enabled me to save hundreds of women from reexcision surgery over the last 5 years.”

False positives vs. false negatives when evaluating margins

It is possible to have a false positive margin reading when using MarginProbe, but Dr. Sebastian believes the gains far outweigh any issues this may cause. “It is true that not all positive readings are truly positive,” she said. “But more significantly, there is a very low rate of false negatives. It’s the negative readings from the probe that are the most powerful part. When there is a positive reading, it’s for me to decide if I will reexcise that margin—which I do in the vast majority of the cases because I want to prevent an additional trip to the OR for the patient. Nothing in medicine is perfect. There’s still a role for physician and surgeon judgment. But if you use information from MarginProbe in a consistent and reliable way, you cannot help but to improve your patient care.”

Additional Marginprobe benefits

Dr. Sebastian spotlighted other ways that MarginProbe makes a difference in the lives of patients. “By eliminating reexcision, I’ve been able to care for more women over the years, as using MarginProbe frees up time in the operating room,” she said. “It also helps with performing oncoplastic surgery concurrent with a lumpectomy. While still in the OR, I can have confidence that those margins will be negative so I can rearrange the tissue to improve cosmetic outcomes—that’s a home run.”

“In breast cancer surgery none of us can afford to sit still,” the physician continued. “Keeping up to date is of paramount importance and I think MarginProbe is just one of those examples. Sometimes the key to better outcomes is not only identifying problems for surgeons, but giving them the tools to address it. I like the fact that I’m a part of implementing such a powerful change in women’s care.”

Molly Sebastian, MD, FACS

  • Medical Director at the Reinsch Pierce Family Center for Breast Health at Virginia Hospital Center
  • Education: University of Virginia School of Medicine, Charlottesville VA
  • Residency: Medical College of Virginia School of Medicine, Richmond VA
  • Fellowship: National Institutes of Health Research Fellowship, John Hopkins Hospital, Baltimore MD
  • Certified by the American Board of Surgery and a member of the Association of Women Surgeons.
  • Virginia Hospital Center’s physician liaison to the American College of Surgeons’ Commission on Cancer
  • Member of the Education Committee of the American Society of Breast Surgeons

Virginia Hospital Center

  • 342-bed, all-private-room facility
  • One of America’s 100 Top Hospitals® for 2013
  • Ranked number one in the Commonwealth of Virginia for patient satisfaction

Disclaimer: The views and opinions expressed  in this article are those of the authors and do not necessarily reflect the official policy or position of Dilon.