Quality measures in breast cancer surgery.

The development of accurate quality performance measures in breast cancer surgery is extremely challenging as highlighted by Monica Morrow in a recent editorial. Traditional quality measures in surgical oncology have focused on 30-day morbidity and mortality which are not relevant to breast cancer surgery which is typically associated with low morbidity and mortality. Dr Morrow suggests that the recent study by McCahill et al which uses re-excision of margins following breast conserving surgery (BCS) as an indicator of surgical quality fails the lithmus test as a quality measure for a variety of reasons. Essentially, there are too many variables that may influence the decision to proceed with breast conserving surgery in the first place such as patients’ age, surgeons’ bias and appropriate preoperative imaging. Using re-excision of margins as a tool to measure quality would encourage breast surgeons to perform a wider excision than is oncologically necessary and compromise the aesthetic appearance of the breast. In addition the quality of pathological margin processing may also vary considerably between institutions. It is therefore essential that any proposed quality measure in breast cancer surgery is evidence based and compliments our understanding of modern breast cancer biology. It is equally important that any proposed quality indicator is reliable and appropriately validated and is cost-effective in terms of collecting the relevant data.