Annals of Surgical Oncology

, Volume 25, Issue 10, pp 2965–2974 | Cite as

American Society of Breast Surgeons’ Practice Patterns After Publication of the SSO-ASTRO-ASCO DCIS Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation

  • Sarah M. DeSnyderEmail author
  • Kelly K. Hunt
  • Wenli Dong
  • Benjamin D. Smith
  • Meena S. Moran
  • Mariana Chavez-MacGregor
  • Yu Shen
  • Henry M. Kuerer
  • Anthony Lucci
Breast Oncology



The SSO-ASTRO-ASCO consensus guideline on margins for breast-conserving surgery with whole breast irradiation in ductal carcinoma in situ (DCIS) recommended a 2-mm margin. We sought to determine the impact of guideline publication on clinician practice.


A total of 3081 members of the American Society of Breast Surgeons (ASBrS) received a survey. Respondents’ clinical practice type and duration, guideline familiarity, and margin width preferences before and after publication were assessed. Clinical practice pattern differences before and after publication were investigated using McNemar’s test.


A total of 767 (24.9%) of those surveyed responded. Most (92.4%) indicated guideline familiarity. Of those familiar, re-excision preference for DCIS and a positive margin remained the same before (94.4%) and after (94.3%) publication (McNemar’s test p = 1.0). Following publication, surgeons were more likely to avoid re-excision to achieve margins wider than 2-mm (82.3% pre versus 87.5% post, p = 0.002). More surgeons performed re-excision for a close margin with pure DCIS (25.9% pre versus 36.5% post, p < 0.001) and with DCIS with microinvasion (DCIS-M) (40.7% pre versus 52.3% post, p < 0.001). For patients with invasive disease with extensive intraductal component (EIC) and a close margin, preference to avoid re-excision was similar (51.2% per versus 55.2% post, p = 0.071).


Since guideline publication, surgeons are less likely to perform re-excision to obtain a margin greater than 2-mm and more likely to perform re-excision to obtain a 2-mm margin for both pure DCIS and DCIS-M. Preference to avoid re-excision with a close margin and EIC was similar before and after publication.



We thank Antoinette Smithson for assistance with preparation of the manuscript.




  1. 1.
    Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol. 1998;16:441–52.CrossRefGoogle Scholar
  2. 2.
    Houghton J, George WD, Cuzick J, et al. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet. 2003;362:95–102.CrossRefGoogle Scholar
  3. 3.
    Emdin SO, Granstrand B, Ringberg A, et al. SweDCIS: radiotherapy after sector resection for ductal carcinoma in situ of the breast: results of a randomised trial in a population offered mammography screening. Acta Oncol. 2006;45:536–43.CrossRefGoogle Scholar
  4. 4.
    Julien JP, Bijker N, Fentiman IS, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet. 2000;355:528–33.CrossRefGoogle Scholar
  5. 5.
    McCormick B, Winter K, Hudis C, et al. RTOG 9804: a prospective randomized trial for good-risk ductal carcinoma in situ comparing radiotherapy with observation. J Clin Oncol. 2015;33:709–15.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Taghian A, Mohiuddin M, Jagsi R, Goldberg S, Ceilley E, Powell S. Current perceptions regarding surgical margin status after breast-conserving therapy: results of a survey. Ann Surg. 2005;241:629–39.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Azu M, Abrahamse P, Katz SJ, Jagsi R, Morrow M. What is an adequate margin for breast-conserving surgery? Surgeon attitudes and correlates. Ann Surg Oncol. 2010;17:558–63.CrossRefGoogle Scholar
  8. 8.
    Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for treatment of breast cancer. JAMA. 2009;302:1551–6.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Olsen MA, Nickel KB, Margenthaler JA, et al. Increased risk of surgical-site infection among breast-conserving surgery reexcisions. Ann Surg Oncol. 2015;22:2003–9.CrossRefGoogle Scholar
  10. 10.
    Greenup RA, Peppercorn J, Worni M, Hwang ES. Cost implications of the SSO-ASTRO consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. Ann Surg Oncol. 2014;21:1512–4.CrossRefGoogle Scholar
  11. 11.
    King TA, Sakr R, Patil S, et al. Clinical management factors contribute to the decision for contralateral prophylactic mastectomy. J Clin Oncol. 2011;29:2158–64.CrossRefGoogle Scholar
  12. 12.
    Morrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology–American Society for Radiation Oncology–American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. Ann Surg Oncol. 2016;23:3801–10.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Kuerer HM, Smith BD, Chavez-MacGregor M, et al. DCIS margins and breast conservation: MD Anderson Cancer Center multidisciplinary practice guidelines and outcomes. J Cancer. 2017;8:2653–62.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Van Zee KJ, Subhedar P, Olcese C, Patil S, Morrow M. Relationship between margin width and recurrence of ductal carcinoma in situ: analysis of 2996 women treated with breast-conserving surgery for 30 years. Ann Surg. 2015;262:623–31.PubMedPubMedCentralGoogle Scholar
  15. 15.
    Tadros AB, Smith BD, Shen Y, et al. Ductal carcinoma in situ and margins < 2 mm: contemporary outcomes with breast conservation. Ann Surg. 2017. Scholar
  16. 16.
    Early Breast Cancer Trialists’ Collaborative Group (EBCTCG), Correa C, McGale P, Taylor C, et al. Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast. J Natl Cancer Inst Monogr. 2010;2010:162–77.CrossRefGoogle Scholar
  17. 17.
    Fisher ER, Costantino J, Fisher B, Palekar AS, Redmond C, Mamounas E. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators. Cancer. 1995;75:1310–9.CrossRefGoogle Scholar
  18. 18.
    Donker M, Litière S, Werutsky G, et al. Breast-conserving treatment with or without radiotherapy in ductal carcinoma in situ: 15-year recurrence rates and outcome after a recurrence, From the EORTC 10853 Randomized Phase III Trial. J Clin Oncol. 2013;31:4054–9.CrossRefGoogle Scholar
  19. 19.
    Marinovich ML, Azizi L, Macaskill P, et al. The association of surgical margins and local recurrence in women with ductal carcinoma in situ treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2016;23:3811–21.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Dunne C, Burke JP, Morrow M, Kell MR. Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ. J Clin Oncol. 2009;27:1615–20.CrossRefGoogle Scholar
  21. 21.
    Wang SY, Chu H, Shamliyan T, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. JNCI J Natl Cancer Inst. 2012;104:507–16.CrossRefGoogle Scholar
  22. 22.
    Moran MS, Schnitt SJ, Giuliano AE, et al. SSO-ASTRO consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stage I and II invasive breast cancer. Int J Radiat Oncol Biol Phys. 2014;88:553–64.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Li Y, Zhang S, Wei X, Zhang J. The clinical features and management of women with ductal carcinoma in situ with microinvasion: a retrospective cohort study. Int J Surg. 2015;19:91–4.CrossRefGoogle Scholar
  24. 24.
    Parikh RR, Haffty BG, Lannin D, Moran MS. Ductal carcinoma—in situ—with microinvasion: prognostic implications, long-term outcomes, and role of axillary evaluation. Int J Radiat Oncol Biol Phys. 2012;82:7–13.CrossRefGoogle Scholar
  25. 25.
    Gradishar WJ, Anderson BO, Balassanian R, et al. Breast cancer, version 4.2017, NCCN clinical practice guidelines in oncology. JNCCN J Natl Compr Cancer Netw. 2018;16:310–20.Google Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Sarah M. DeSnyder
    • 1
    Email author
  • Kelly K. Hunt
    • 1
  • Wenli Dong
    • 2
  • Benjamin D. Smith
    • 3
  • Meena S. Moran
    • 4
  • Mariana Chavez-MacGregor
    • 5
  • Yu Shen
    • 2
  • Henry M. Kuerer
    • 1
  • Anthony Lucci
    • 1
  1. 1.Department of Breast Surgical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Department of BiostatisticsThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of Radiation OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  4. 4.Department of Radiation OncologyYale Cancer CenterNew HavenUSA
  5. 5.Department of Breast Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonUSA

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