Letters Reoperation after breast conservation

Bigger margins are not better in breast conserving surgery

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5855 (Published 04 September 2012) Cite this as: BMJ 2012;345:e5855
  1. J Michael Dixon, professor of breast surgery and consultant surgeon1,
  2. Nehmat Houssami, associate professor, screening and test evaluation programme2
  1. 1Western General Hospital, Edinburgh, UK
  2. 2Sydney Medical School, University of Sydney, Australia
  1. mike.dixon{at}ed.ac.uk

Jeevan and colleagues report that one in five women who have breast conserving surgery requires reoperation because of incomplete excision or inadequate clearance of margins.1 The first major review of surgical margins established that disease at the margins increased recurrence rates but concluded that wide margins compared with narrow margins did not reduce local recurrence.2 A recent meta-analysis of 21 studies that included 14 571 patients with invasive breast cancer found significantly higher local recurrence rates with involved or close margins relative to negative margins.3 However, the study found no significant difference in the risk of local recurrence with ≥2 mm and ≥5 mm margins relative to narrower margins (1 mm) when adjustment was made for follow-up time and proportion of women who received a radiation boost or endocrine treatment. This meta-analysis concluded that a 1 mm negative margin is as good as a wider margin if patients receive optimal adjuvant treatment.

More normal breast tissue is removed with wider margins, resulting in a poorer cosmetic outcome.4 Cosmetic outcome correlates with the patients’ anxiety and depression score, body image, sexuality, and self esteem.4

The authors suggest that “research is urgently needed on how different approaches to margins influence local recurrence.”1 We disagree, given the existing evidence,2 3 and as Morrow and colleagues eloquently argue “Bigger is not better” when considering surgical margins for breast conservation.5 Surgeons should consider abandoning local protocols and follow the evidence: the problem is not so much the variation in reoperation rates but the inconsistency in translating the knowledge base on margin width into clinical practice.


Cite this as: BMJ 2012;345:e5855


  • Competing interests: None declared.


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