A Multi-Center Investigation of Breast-Conserving Surgery Based on Data from the Chinese Society of Breast Surgery (CSBrS-005)
Breast-conserving surgery (BCS) has been established as a standard treatment for early-stage breast cancer, offering survival outcomes comparable to mastectomy while preserving cosmetic appearance. Despite its global acceptance, the implementation of BCS in China has historically lagged behind that in Western countries, with limited data reflecting its real-world application. This multi-center cross-sectional study, conducted by the Chinese Society of Breast Surgery (CSBrS), aimed to characterize the current status of BCS in China through a comprehensive analysis of clinical and pathological data from 34 member hospitals between January and December 2018.
Background and Rationale
The shift toward BCS began with landmark trials in the 1980s and 1990s, which demonstrated equivalent survival rates and improved quality of life compared to mastectomy. By 1991, the National Institutes of Health endorsed BCS for early-stage breast cancer, catalyzing its widespread adoption in developed nations. However, in China, factors such as late-stage diagnoses, limited screening programs, and patient or clinician preferences for mastectomy have contributed to lower BCS rates. Prior studies reported a national BCS rate of 11.88% in 2008, though select centers in southern China achieved rates exceeding 50%, closer to Western benchmarks. Understanding the disparities in BCS adoption and the clinical characteristics of patients undergoing this procedure is critical for improving care standards.
Study Design and Methodology
This retrospective study analyzed data from 34 CSBrS-affiliated hospitals, representing seven geographic regions: Northeast, North, East, South, Central, Northwest, and Southwest China. Eligible patients were women with histologically confirmed breast cancer who underwent BCS, excluding those with distant metastases, inflammatory breast cancer, or male breast cancer. Data were collected via standardized electronic questionnaires, capturing demographic, clinical, and pathological variables, including tumor size, neoadjuvant therapy use, surgical margins, lymph node involvement, and molecular subtypes. Margin width was classified as ≤2 mm, 2–5 mm, or >5 mm, with positive margins defined as tumor presence at the resection edge.
Key Findings
Regional Variation in BCS Rates
Among 30,494 breast cancer surgeries performed in 2018, 4,459 (14.6%) were BCS procedures. Regional disparities were striking: South China reported the highest BCS rate (47.1%), followed by North China (23.3%), while Northeast China had the lowest rate (8.9%). These variations highlight uneven adoption of BCS across China, potentially influenced by differences in clinical expertise, patient education, and healthcare infrastructure.
Patient and Tumor Characteristics
The cohort had a mean age of 48.7 ± 11.2 years, with 19.8% of patients younger than 40 and 2.3% older than 75. Most patients (58.2%) were premenopausal. Tumors were predominantly localized to the left breast (51.5%) and the lateral upper quadrant (49.4%). Family history of breast cancer was reported in 5.3% of patients, and 7.9% had a family history of other malignancies.
Tumor size data were available for 2,754 patients: 61.2% had tumors ≤2 cm, 29.3% measured 2–3 cm, 6.4% were 3–4 cm, and 3.2% exceeded 4 cm. Notably, 10.2% of patients received neoadjuvant therapy, a strategy to downstage tumors and increase eligibility for BCS. Axillary surgery included sentinel lymph node biopsy (SLNB) in 80.7% and axillary lymph node dissection (ALND) in 19.3%. Pathologically negative lymph nodes were observed in 76.9% of cases, while 17.7% had 1–3 positive nodes and 5.3% had ≥4 positive nodes.
Invasive ductal carcinoma (IDC) accounted for 63.8% of cases, followed by ductal carcinoma in situ (DCIS; 11.0%). Molecular subtypes included luminal B (58.0%), luminal A (23.2%), triple-negative breast cancer (TNBC; 12.7%), and HER2-positive (6.1%).
Surgical Margins
Margin status was reported for 3,119 patients, with positive margins identified in 7.3% of initial excisions, necessitating re-excision. Among 1,734 patients with recorded margin widths, 88.2% had margins >5 mm, 9.8% had 2–5 mm, and 2.0% had ≤2 mm. Notably, IDC cases with margins ≤2 mm comprised 1.9% of the cohort, while DCIS cases with similar margins were rare (0.7%). These findings reflect a conservative approach to margin assessment in Chinese practice, prioritizing wide excisions to minimize recurrence risk.
Discussion
Low National BCS Rates and Regional Disparities
The overall BCS rate of 14.6% underscores persistent challenges in China, despite improvements since 2008. The high rate in South China (47.1%) aligns with advanced centers like Sun Yat-sen Memorial Hospital, where BCS adoption mirrors Western patterns. Conversely, lower rates in Northeast and Northwest China may stem from limited access to radiation therapy, patient misconceptions about recurrence risks, or surgeon preferences. Efforts to standardize BCS guidelines and expand training programs could mitigate these disparities.
Tumor Characteristics and Neoadjuvant Therapy
The predominance of small tumors (≤2 cm) in this cohort (61.2%) suggests appropriate patient selection for BCS. However, the low utilization of neoadjuvant therapy (10.2%) contrasts with Western practices, where neoadjuvant regimens are routinely used to shrink tumors and increase BCS eligibility. Promoting neoadjuvant therapy, particularly in regions with high rates of advanced-stage diagnoses, could further enhance BCS adoption.
Margin Practices and Clinical Implications
Chinese surgeons’ preference for wide margins (>5 mm in 88.2% of cases) contrasts with the “no ink on tumor” standard endorsed by international guidelines. While wider margins reduce re-excision rates, they may compromise cosmetic outcomes. The low positive margin rate (7.3%) reflects meticulous intraoperative frozen section analysis, a common practice in China. However, this approach increases surgical complexity and resource utilization, highlighting the need for balanced, evidence-based margin guidelines tailored to local contexts.
Limitations
This study’s focus on high-volume, CSBrS-affiliated tertiary hospitals may overestimate national BCS rates, as rural or lower-tier facilities likely have lower adoption. Missing data on tumor size (38.2%) and margin width (61.1%) limit the generalizability of certain findings. Prospective studies with standardized data collection are needed to validate these observations.
Conclusion
This CSBrS-led investigation provides the largest contemporary analysis of BCS practice in China, revealing incremental progress amid persistent regional inequities. The findings emphasize the need for targeted interventions—such as surgeon education, patient counseling, and enhanced radiation therapy access—to expand BCS utilization. Standardizing margin assessment protocols and integrating neoadjuvant therapy into treatment pathways could further optimize outcomes. Future research should explore long-term survival and recurrence data to reinforce the safety and efficacy of BCS in diverse Chinese populations.
doi.org/10.1097/CM9.0000000000001152
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