It is well-known that breast-conserving surgery yields the same survival as mastectomy for patients with breast cancer, and it has become the mainstay of surgical therapy for the majority of patients with early-stage disease. Critical to the success of breast-conserving surgery, however, is the achievement of negative margins; a meta-analysis has demonstrated that positive margins have been associated with a 2-fold increase in local recurrence rates.

Hence, positive margins often result in reexcision. Neither surgeons nor patients want to return to the operating room for another procedure, yet positive margins are found in 20% to 40% of breast cancer cases,

 prompting reexcision— an event touted as the “other breast cancer epidemic.”

Debate is ongoing about what constitutes a positive margin, but recent consensus statements have described a positive margin as tumor at ink for invasive carcinoma,

 or within 2 mm for ductal carcinoma in situ (DCIS).

 For DCIS that is concomitant with invasive disease, without an extensive intraductal component, margins are considered negative if DCIS is not at ink (even if within 2 mm).

 This revision in the definition of a positive margin has resulted in a decline of reexcision rates

; however, the long-term impact of this revision remains to be well elucidated.

Indeed, margin status does not (in absolute terms) predict residual disease.

 Roughly 50% of patients with positive margins will have no further disease and 12% to 14% of patients with negative margins will have cancer left in situ adjacent to the cavity resected. Given that margin evaluation is not an exact science, there remains debate, therefore, on whether all positive margins require reexcision, especially for focal disease,

 etc. Data are mixed on the oncologic safety of avoiding reexcision in such patients, so the maxim remains to recommend reexcision for all positive margins.

A number of techniques have been evaluated for their value in reducing positive margin rates. To begin, some have felt that the use of preoperative MRI may better define extent of disease and may therefore reduce the positive margin rate by better guiding surgical resection. Sadly, the 2 randomized controlled trials that have evaluated this have not validated this hypothesis: The COMICE trial

 found no difference in positive margin rates between patients who had preoperative MRI and those who did not, and the MONET trial

 paradoxically demonstrated an increase in positive margins associated with the use of preoperative MRI. Some have argued that the value of preoperative MRI may be more evident in patients presenting with DCIS, which tends to be less cohesive and more likely to result in positive margins. However, a recent metaanalysis found that MRI did not significantly affect margin status nor reexcision rates in these patients.

Others have evaluated various methods of localization of nonpalpable tumors. Although a Cochrane analysis found that no significant differences exist among wire localization, radio-occult lesion localization, and radioactive seed localization in terms of margin positivity and reexcision rates,

 use of intraoperative ultrasound seems to result in a lower positive margin rate. A meta-analysis of 7 prospective studies found that the odds of achievement of negative margins were significantly higher with the use of intraoperative ultrasound (risk ratio, 1.37; 95% CI, 1.18-1.59).

 Still others have argued that intraoperative evaluation of margins may be helpful in reducing positive margin rates. Some utilize intraoperative touch imprint cytology or frozen section, both of which require pathology expertise and may add to operative time. Many surgeons will resect margins where intraoperative imaging suggests a close margin. However, studies that have evaluated this in a robust fashion have not found this to reduce positive margin rates.

Resection of circumferential cavity shave margins, however, seems to consistently reduce positive margin and reexcision rates in both retrospective and prospective studies (

). Three randomized controlled trials to date have all demonstrated that resection of cavity shave margins reduces positive margin and reexcision rates by at least 50%.

The SHAVE trial was the first randomized controlled trial to evaluate this technique. Inclusion criteria included patients undergoing partial mastectomy for stage 0 to III breast cancer. For patients enrolled in the trial after informed consent, surgeons were advised to perform their best operation, including the resection of any margins deemed close on either intraoperative imaging or gross evaluation.

Once the surgeon was ready to close, patients were randomized intraoperatively to either “shave”—that is, have circumferential cavity shave margins resected&mdash;or “no shave” in which the surgeon was advised to close. The “shave” procedure added 10 minutes to operative time and did not result in an increase in postoperative seromas, hematomas, or infections. However, patients in the “shave” arm had a significantly lower rate of positive margins and need for reexcision than those in the “no shave” arm.

Although these findings were practice-changing for some, others criticized the study for a number of reasons. First, SHAVE was a singlecenter study, and some questioned whether the results would be externally generalizable. In addition, some argued that the technique of resecting cavity shave margins may be of limited utility for surgeons who already have a low positive margin rate (<25%), and/or who use oncoplastic surgery.

To address these concerns, SHAVE2 was conducted as a multicenter, randomized controlled trial that involved 9 diverse practices from across the United States. This trial demonstrated that the reductions in positive margin and reexcision rate associated with resection of cavity shave margins hold regardless of practice setting (eg, academic vs private practice), prior positive margin rate, or use of oncoplastic surgery.

Of note, the technique of resection of cavity shave margins does (by definition) yield a higher resection volume. However, the SHAVE trial found that this did not affect patient-reported cosmetic outcome postoperatively. Both the SHAVE and SHAVE2 trials will evaluate the impact of resection of cavity shave margins on cosmetic outcome over time, particularly after radiation therapy.

Further, both trials will evaluate local recurrence rate at 5 years. It is anticipated that the impact of cavity shave margins on local recurrence rate will be muted in both trials because all patients, regardless of randomization arm, were expected to be offered reexcision if a positive margin was found. Further, with the nearly ubiquitous rate of systemic therapy and radiation therapy, locoregional recurrence rates are expected to be low.

However, not all patients in the trial underwent adjuvant therapy, and in both the SHAVE and SHAVE2 trials, roughly 12% to 14% of patients in the “shave” arm were found to have residual disease in the cavity shave margins even when the initial margin was negative. Therefore, one would speculate that patients in the “no shave” arm may have a higher burden of residual disease; the impact of this on locoregional recurrence, however, remains to be seen.

How vigorously we pursue positive margins remains a question to be answered. The SHAVE trial found that of 31 margin-positive patients randomized to the “shave” arm in whom the positive margin was resected with a cavity shave margin, further disease was found in 16 (51.6%). The positive margin was rendered negative in 8 of those patients. In other words, a positive margin yielded no further disease in ~50% of cases, leading some to question the value of resection of these margins, and/or the ability to predict which cases would have further disease.

Data from the SHAVE and SHAVE2 trials, in terms of long-term outcomes vis-à-vis local recurrence, may lend some insight into the impact of adjuvant therapy on reducing the ramifications of a positive margin. For now, however, the achievement of negative margins remains a necessary part of breast-conserving surgery.

Houssami N, Macaskill P, Marinovich ML, Morrow M. The association of surgical margins and local recurrence in women with early-stage invasive breast cancer treated with breast-conserving therapy: a meta-analysis. 

. 2014;21(3):717-730. doi: 10.1245/s10434-014-3480-5.

Wilke LG, Czechura T, Wang C, et al. Repeat surgery after breast conservation for the treatment of stage 0 to II breast carcinoma: a report from the National Cancer Data Base, 2004-2010. 

. 2014;149(12):1296-1305. doi: 10.1001/jamasurg.2014.926.

McCahill LE, Single RM, Aiello Bowles EJ, et al. Variability in reexcision following breast conservation surgery. 

. 2012;307(5):467-475. doi: 10.1001/jama.2012.43.

Cody HS 3rd, Van Zee KJ. Reexcision—the other breast cancer epidemic. 

. 2015;373(6):568-569. doi: 10.1056/NEJMe1507190.

Moran MS, Schnitt SJ, Giuliano AE, et al. Society of Surgical Oncology - American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. 

. 2014;21(3):704-716. doi: 10.1245/s10434-014-3481-4.

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. 

. 2016;23(12):3801-3810. doi: 10.1245/s10434-016-5449-z.

Schulman AM, Mirrielees JA, Leverson G, et al. Reexcision surgery for breast cancer: an analysis of the American Society of Breast Surgeons (ASBrS) MasterySM database following the SSO-ASTRO “no ink on tumor” guidelines. 

. 2017;24(1):52-58. doi: 10.1245/s10434-016-5516-5.

Mimouni M, Lecuru F, Rouzier R, et al. Reexcision for positive margins in breast cancer: a predictive score of residual disease. 

. 2015;24(3):129-135. doi: 10.1016/j.suronc.2015.08.003.

Park CC, Mitsumori M, Nixon A, et al. Outcome at 8 years after breast-conserving surgery and radiation therapy for invasive breast cancer: influence of margin status and systemic therapy on local recurrence. 

. 2000;18(8):1668-1675. doi: 10.1200/JCO.2000.18.8.1668.

Mullen R, Macaskill EJ, Khalil A, et al. Involved anterior margins after breast conserving surgery: is re-excision required? 

. 2012;38(4):302-306. doi: 10.1016/j.ejso.2012.01.004.

Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. 

. 2010;375(9714):563-571. doi: 10.1016/S0140-6736(09)62070-5.

Peters NH, van Esser S, van den Bosch MA, et al. Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET - randomised controlled trial. 

. 2011;47(6):879-886. doi: 10.1016/j.ejca.2010.11.035.

Fancellu A, Turner RM, Dixon JM, et al. Meta-analysis of the effect of preoperative breast MRI on the surgical management of ductal carcinoma in situ. 

. 2015;102(8):883-893. doi: 10.1002/bjs.9797.

Chan BK, Wiseberg-Firtell JA, Jois RH, et al. Localization techniques for guided surgical excision of non-palpable breast lesions. 

. 2015;(12):CD009206. doi: 10.1002/14651858.CD009206.pub2.

Pan H, Wu N, Ding H, et al. Intraoperative ultrasound guidance is associated with clear lumpectomy margins for breast cancer: a systematic review and meta-analysis. 

. 2013;8(9):e74028. doi: 10.1371/journal.pone.0074028.

Chagpar AB, Butler M, Killelea BK, et al. Does three-dimensional intraoperative specimen imaging reduce the need for re-excision in breast cancer patients? a prospective cohort study. 

. 2015;210(5):886-890. doi: 10.1016/j.amjsurg.2015.05.018.

Chagpar AB, Killelea BK, Tsangaris TN, et al. A randomized, controlled trial of cavity shave margins in breast cancer. 

. 2015;373(6):503-510. doi: 10.1056/NEJMoa1504473.

Jones V, Linebarger J, Perez S, et al. Excising additional margins at initial breast-conserving surgery (BCS) reduces the need for re-excision in a predominantly African American population: a report of a randomized prospective study in a public hospital. 

. 2016;23(2):456-464. doi: 10.1245/s10434-015-4789-4.

Corsi F, Sorrentino L, Bonzini M, et al. Cavity shaving reduces involved margins and reinterventions without increasing costs in breast-conserving surgery: a propensity score-matched study. 

. 2017;24(6):1516-1524. doi: 10.1245/s10434-017-5774-x.

Marudanayagam R, Singhal R, Tanchel B, et al. Effect of cavity shaving on reoperation rate following breast-conserving surgery. 

. 2008;14(6):570-573. doi: 10.1111/j.1524-4741.2008.00649.x.

Unzeitig A, Kobbermann A, Xie XJ, et al. Influence of surgical technique on mastectomy and reexcision rates in breast-conserving therapy for cancer. 

. 2012;2012:725121. doi: 10.1155/2012/725121.

Rizzo M, Iyengar R, Gabram SG, et al. The effects of additional tumor cavity sampling at the time of breast-conserving surgery on final margin status, volume of resection, and pathologist workload. 

. 2010;17(1):228-234. doi: 10.1245/s10434-009-0643-x.

Kobbermann A, Unzeitig A, Xie XJ, et al. Impact of routine cavity shave margins on breast cancer re-excision rates. 

. 2011;18(5):1349-1355. doi: 10.1245/s10434-010-1420-6.

View more from the 2019 Miami Breast Cancer Conference

Articles

Data from the SHAVE and SHAVE2 trials, in terms of long-term outcomes vis-à-vis local recurrence, may lend some insight into the impact of adjuvant therapy on reducing the ramifications of a positive margin.

Intraoperative Shave Technique Proves Effective in Breast-Conserving Surgery

Patients with distant metastatic disease at presentation constitute 3% to 10% of patients with breast cancer. Historically, these patients have been considered to have systemic disease that cannot be treated with surgery for curative intent. This is often a devastating diagnosis for a patient, who is faced with only palliative options.

The rate of resection of primary breast cancer in the setting of distant metastatic disease has fallen dramatically over the past decade,

 but results from recent studies may alter this trend. Particularly with the more widespread use of effective systemic therapy, the potential to bring patients to the point of “no evidence of disease” via resection of the primary tumor is greater now than ever before.

Further, several authors have hypothesized that resection of the primary tumor may eliminate tumor stem cells and remove a source of tumor-induced immunosuppression, such that resection of the primary tumor may not only reduce tumor burden locally but also help in the clearance of systemic disease.

Although a number of retrospective studies have found that resection of the primary tumor in such patients is associated with improved survival, this is not uniformly the case. Nonetheless, a recent meta-analysis found that surgical resection of the primary tumor was associated with a hazard ratio (HR) for death of 0.63 (95% CI, 0.58-0.70).

 It is unclear, however, whether this improvement in overall survival (OS) represents the true effect of debulking or is simply reflective of the inherent selection bias favoring healthier patients with a lower tumor burden as surgical candidates.

Randomized controlled trials to elucidate the true impact of surgery in the setting of metastatic disease have produced seemingly conflicting results. Badwe et al reported the findings of an Indian trial (NCT00193778) in which 350 patients with metastatic disease were treated with systemic therapy and subsequently randomized to receive surgery or not.

 In this study, there was no significant difference in OS at 2 years of follow-up between the 2 groups (41.9% vs 43.0%, respectively; HR, 1.04; 95% CI, 0.81-1.34; 

 = .79). Although patients treated with surgery in this study tended to have a lower rate of locoregional recurrence, they had a higher rate of progression to distant metastases.

Soran et al, on the other hand, in their trial of 274 Turkish patients who presented with metastatic disease, randomized patients to surgical resection versus no resection prior to systemic therapy.

 Their results were similar to those of the Indian trial in terms of OS when patients were followed to 3 years (OS, 68% vs 51%; 

 = .79), but with 5 years of follow-up, investigators found a significant improvement in OS associated with surgery (41.6% vs 24.4%; HR, 0.66; 95% CI, 0.49-0.88; 

There are a number of factors that may help to reconcile the disparate outcomes of these 2 studies. First of all, the Turkish study had a longer follow-up: At 3 years, its findings were similar to those of the Indian trial. Secondly, in the Turkish trial, patients had surgery first; in the Indian trial, patients were treated with systemic therapy first.

Given the results of the National Surgical Adjuvant Breast and Bowel Project B-18 trial in the nonmetastatic setting, which showed no difference in survival in patients treated with neoadjuvant therapy followed by surgery versus surgery followed by adjuvant therapy, it is difficult to surmise how this could account for the difference, particularly when the response to treatment may be an indicator of improvement in survival with surgical resection (a question being posed by the ongoing ECOG trial).

Third, the patients in the 2 trials varied in their clinicopathologic features. The Indian trial had significantly more patients who had more than 3 metastatic sites at presentation (74% vs 40%), and patients were less likely to be estrogen receptor—positive (60% vs 80%). Finally, the use of targeted therapy varied in the 2 trials, with only 28% of HER2-positive patients receiving trastuzumab (Herceptin) in the Indian trial versus nearly 100% in the Turkish trial.

A number of studies have found that factors such as younger age, fewer comorbidities, fewer metastatic sites, bone-only disease, and a good response to chemotherapy are all associated with improved outcomes in patients undergoing surgery of the primary tumor. It may be the case, therefore, that surgery for the primary tumor is efficacious only in a certain subpopulation of patients with metastatic disease; but this cohort remains to be well defined.

In addition, any potential benefit of surgery in the setting of metastatic disease must be balanced against the risks of operative intervention. There are data to suggest that surgery in the setting of metastatic disease is associated with a higher 30-day morbidity than in the nonmetastatic setting, elevating risks of complications such as bleeding requiring transfusion and thromboembolic events, such as deep vein thrombosis and pulmonary embolism.

Currently, most patients with metastatic disease are treated with palliative intent, with surgery reserved for local wound control. However, there are several randomized controlled trials that are still ongoing to evaluate the impact of surgery for the primary breast cancer on OS in patients with metastatic disease. Further studies are required to assess surgery’s impact on quality of life. As our understanding of tumor biology improves and our armamentarium of effective systemic therapies grows, it is quite possible that, at least for a select group of patients with otherwise well-controlled metastatic disease, surgical resection of the primary tumor may become standard of care in the future.

Thomas A, Khan SA, Chrischilles EA, Schroeder MC. Initial surgery and survival in stage iv breast cancer in the United States, 1988-2011. 

2016;151(5):424-31. doi: 10.1001/jamasurg.2015.4539..

Headon H, Wazir U, Kasem A, Mokbel K. Surgical treatment of the primary tumour improves the overall survival in patients with metastatic breast cancer: a systematic review and meta-analysis. 

 2016;4(5):863-867. doi: 10.3892/mco.2016.778.

Badwe R, Hawaldar R, Nair N, et al. Locoregional treatment versus no treatment of the primary tumour in metastatic breast cancer: an open-label randomised controlled trial. 

2015;16(13):1380-1388. doi: 10.1016/S1470-2045(15)00135-7.

Soran A, Ozmen V, Ozbas S, et al. A randomized controlled trial evaluating resection of the primary breast tumor in women presenting with de novo stage IV breast cancer. 

2016;34(suppl; abstr 1005). meetinglibrary.asco.org/record/122669/abstract.

Cordeiro E, Jackson TD, Elnahas A, et al. Higher rate of breast surgery complications in patients with metastatic breast cancer: an analysis of the NSQIP database. 

2014;21(10):3167- 3172. doi: 10.1245/s10434-014-3959-0.

The rate of resection of primary breast cancer in the setting of distant metastatic disease has fallen dramatically over the past decade, but results from recent studies may alter this trend.

Taking a New Look at Primary Resection in Distant Metastatic Breast Cancer

		Anees B. Chagpar, MD, MSc, MPH, MA, MBA

	Associate Professor, Department of Surgery

	Director, The Breast Center, Smilow Cancer Hospital at Yale-New Haven

	Assistant Director for Diversity and Health Equity, Yale Comprehensive Cancer Center

	Program Director, Yale Interdisciplinary Breast Fellowship

It is well known that healthcare spending in the United States is unsustainable. It is also well known that despite spending a record $2.8 trillion on healthcare annually (17.2% of GDP in 2012)—more than any other nation&mdash;our health outcomes lag behind.

Certain patterns in breast cancer care serve as a microcosm of this debacle. How we screen and work up the more than 235,000 people who are diagnosed with breast cancer every year

, and provide surveillance for the more than 2.8 million breast cancer survivors in this country

 remain a source of considerable controversy and variation in terms of cost.

Yet, there are evidence-based guidelines that provide a more value-based approach that may more aptly address the triple aim of providing the best care, at the lowest cost, for the entire population.

When to start screening, with what modality, how frequently, and when to stop continue to be questions that oncologists face. The 2009 United States Preventive Services Task Force (USPSTF) recommendations, which caused quite an uproar, noted that the majority of the data from randomized controlled trials demonstrating the benefit of mammography were generatedin women between the ages of 50 and 74 years. Furthermore, the recent Canadian randomized controlled trial of nearly 90,000 women followed for more than 20 years demonstrated no improvement in survival and a 22% overdiagnosis rate for women aged 40 to 59 years who underwent screening mammography.

Nonetheless, the American Cancer Society, the National Comprehensive Cancer Network, and the 2002 USPSTF guidelines (now accepted by the Affordable Care Act) all endorse the traditional standard of screening with annual mammography for all women over the age of 40 years. 

When to stop screening is also controversial, since there is insufficient evidence of additional benefit or harm in women over the age of 75 years; however, the annual cost for screening in this population exceeds $410 million.

This is not to argue that no woman over this age should have a mammogram; rather, the decision to screen in this population should be individualized based on patient comorbidities and desires.It makes little sense to screen patients who would likely elect not to treat a small area of cancer or ductal carcinoma in situ detected through a mammogram.

How we screen for breast cancer has also been the subject of some debate. Recent studies have found that the cost of screening in the Medicare population has increased over time, largely due to newer technology, with no significant stage migration.

 The addition of screening ultrasound, particularly for women with dense breasts, may be useful, and the introduction of tomosynthesis holds promise to find more cancers earlier with fewer call-backs. Yet, one wonders about the true effect of all of these screening efforts in reducing mortality due to breast cancer given that, despite an increase in early-stage breast cancers, there has not been a similar concomitant decline in advanced malignancy over the past three decades.

Once patients are diagnosed with cancer, how patients are worked up for extent of disease is another area of considerable controversy. While some have continued to order routine breast MRI, it has become increasingly clear that such practices do not improve outcomes. Adding to the COMICE

 trial data that MRI does not decrease re-excision rates, a recently published individual meta-analysis found that there was no reduction in local or distant recurrence with the use of preoperative MRI.

 Certainly, there will be some patients who will benefit from the addition of MRI, but to have a “one size fits all” approach to preoperative workup seems rather simplistic.

		The chart illustrates the top 30 countries in the world ranked by life expectancy and corresponding healthcare spending based on 2000 statistics. The international dollar is a hypothetical unit of currency that compares what a dollar would buy in goods and services in a given country with comparable purchases that a US dollar would buy in the United States.

		Source Money alone does not extend lives. UC Atlas of Global Inequality website. http://ucatlas.ucsc.edu/index.php. Accessed September 23, 2014.

It is critical that we understand the potential yield of the studies we order, and avoid overuse of diagnostic tests that are not only unlikely to be helpful, but may also add to cost, radiation exposure, and/or otherwise unnecessary downstream invasive procedures carrying their own risks. 

The “Choosing Wisely” campaign has highlighted for oncologists sources of potential waste.  One of the Top Five recommendations from the American Society of Clinical Oncology (ASCO) in 2012, for example, was “[to not] perform PET, CT, and radionuclide bone scans in staging of early breast cancer at low risk of metastasis.” Yet, perhaps due to defensive medicine concerns or anecdotal experience, many continue to order metastatic workups on patients with stage I and II disease.

When one considers the growing number of survivors in this country, our surveillance practices become of significant interest.  Again, ASCO recommends against testing with biomarkers or imaging for asymptomatic individuals treated for breast cancer with curative intent.

Some have used the hyperbole of “money not being an issue” when it comes to cancer; “spare no expense.” I would argue, however, that one needs to consider the 

 for our healthcare dollar; this is not simply about costs, but also about outcomes.

Without concomitant improvements in outcomes to justify cost, one needs to question our zeal for healthcare spending. Healthcare expenditures in this country are not only unsustainable from a societal perspective, but also impair the quality of life for individual patients faced with the financial burden associated with cancer care.

The imperative is therefore clear. We need to do better in terms of deriving value—that is, better outcomes at lower cost for our patients. A critical appraisal of how we screen, workup, and provide ongoing surveillance for our breast cancer patients may be a first step in this direction.

			Garber S, Gates SM, Keeler EB, et al; Rand Corporation. Redirecting innovation in U.S. health care: options to decrease spending and increase value. Published 2014. http://www.rand.org/pubs/research_reports/RR308.html. Accessed September 23, 2014.

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			Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. 

			Miller AB, Wall C, Baines CJ, et al. Twenty five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomised screening trial. 

			Gross CP, Long JB, Ross JS, et al. The cost of breast cancer screening in the Medicare population. 

			Killelea BK, Long JB, Chagpar AB, et al. Evolution of breast cancer screening in the Medicare population: clinical and economic implications. 

			Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. 

			Turnbull L, Brown S, Harvey I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. 

			Peters NH, van Esser S, van den Bosch MA, et al. Preoperative MRI and surgical management in patients with nonpalpable breast cancer: the MONET-randomised controlled trial [published online December 30, 2010]. 

			Houssami N, Turner R, Macaskill P, et al. An individual person data meta-analysis of preoperative magnetic resonance imaging and breast cancer recurrence [published online January 6, 2014]. 

			Schnipper LE, Smith TJ, Raghavan D, et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology [published online April 3, 2012].

			Fenn KM, Evans SB, McCorkle R, et al. impact of financial burden of cancer on survivors' quality of life [published online May 27, 2014]. 

It is well known that healthcare spending in the United States is unsustainable. It is also well known that despite spending a record $2.8 trillion on healthcare annually (17.2% of GDP in 2012)-more than any other nation-our health outcomes lag behind.

Anees B. Chagpar, MD, MSc, MPH, MA, MBA

Articles

Intraoperative Shave Technique Proves Effective in Breast-Conserving Surgery

Taking a New Look at Primary Resection in Distant Metastatic Breast Cancer

Taking a Value-Based Approach to Breast Cancer Screening, Workup, and Surveillance