Interprofessional education in cancer care - a scoping review.

BACKGROUND: Comprehensive cancer care requires effective collaboration by interprofessional healthcare teams. The need to develop educational initiatives to improve interprofessional collaboration is increasingly recognised. However, there is no agreement regarding the interprofessional competencies required for effective cancer care leading to much variation on the focus of research, planning and managing change. A scoping review was conducted to identify the current status of IPE in cancer care and to summarise the results of previous research in order to guide the development of interprofessional education in cancer care. METHODS: The JBI Scoping Review guidelines were used to guide the process of the review. A search of the available literature was conducted in CINAHL, MEDLINE (Ovid), PubMed, PsycInfo, Scopus databases from January 2012 to March 2023 to investigate IPE for health professional clinicians working in cancer care. RESULTS: Of the 825 initial references and 153 studies imported for screening, a total of 28 studies were included in the final review. From those studies, seven focused on the need for IPE and interprofessional competence for oncology healthcare professionals, four reviewed existing IPE programs and 17 described the development and evaluation of interprofessional education. Findings show variation and lack of concept definitions underpinning research in IPE in cancer care settings. Variation also exists in the range of research activities in IPE, most notably related to communication, teamwork and the development of interprofessional practice. The evaluation of impact of IPE is mainly focused on health care professionals' self-evaluation and general feedback. Impact on patient care was only evaluated in one study. CONCLUSIONS: Based on the results, interprofessional education research in the field of cancer care is limited in Europe. Thus, there is a significant increase in publications in the last five years. A more systematic focus on the theoretical framework and definition of concepts would be of value. Research and programme development should be based on a shared understanding on what constitutes the interprofessional competences and IPE. Programmes to develop interprofessional practice should be developed and implemented systematically with inclusion of validated assessment methods, and evaluated and improved regularly.

An inter-specialty cancer training programme curriculum for Europe.

INTRODUCTION: Multidisciplinary and multi-professional collaboration is vital in providing better outcomes for patients The aim of the INTERACT-EUROPE Project (Wide Ranging Cooperation and Cutting Edge Innovation As A Response To Cancer Training Needs) was to develop an inter-specialty curriculum. A pilot project will enable a pioneer cohort to acquire a sample of the competencies needed. METHODS: A scoping review, qualitative and quantitative surveys were undertaken. The quantitative survey results are reported here. Respondents, including members of education boards, curriculum committees, trainee committees of European specialist societies and the ECO Patient Advisory Committee, were asked to score 127 proposed competencies on a 7-point Likert scale as to their value in achieving the aims of the curriculum. Results were discussed and competencies developed at two stakeholder meetings. A consultative document, shared with stakeholders and available online, requested views regarding the other components of the curriculum. RESULTS: Eleven competencies were revised, three omitted and three added. The competencies were organised according to the CanMEDS framework with 13 Entrustable Professional Activities, 23 competencies and 127 enabling competencies covering all roles in the framework. Recommendations regarding the infrastructure, organisational aspects, eligibility of trainees and training centres, programme contents, assessment and evaluation were developed using the replies to the consultative document. CONCLUSIONS: An Inter-specialty Cancer Training Programme Curriculum and a pilot programme with virtual and face-to-face components have been developed with the aim of improving the care of people affected by cancer.

Multidisciplinary training of cancer specialists in Europe.

The best care for patients with cancer is most likely to be achieved when decisions about diagnosis, staging and treatment are made at multidisciplinary and multiprofessional meetings, preferably when all the professional expertise relevant to the patient's condition is gathered together. Questionnaires were sent to National Societies of Radiation Oncology and Medical Oncology concerning similarities and differences in training programs and multidisciplinary care in member states in Europe. Results indicated wide variation in training systems and practice. Data were lacking for Surgery because Surgical Oncology is not recognised as a speciality in the EU and most specialist training in cancer surgery is organ based. A period of time in cross-disciplinary training in each of the other two disciplines for all trainees in Medical Oncology, Radiation Oncology and Surgical Oncology (including all surgeons training in cancer surgery) is recommended. This is likely to improve the value of multidisciplinary meetings and may result in improved patient care. The Expert Group on Cancer Control of the European Commission has endorsed this recommendation.

Detected peritoneal fluid in small bowel obstruction is associated with the need for surgical intervention.

BACKGROUND: Predicting the clinical course in adhesional small bowel obstruction is difficult. There are no validated clinical or radiologic features that allow early identification of patients likely to require surgical intervention. METHODS: We conducted a retrospective review of 100 patients consecutively admitted to a tertiary level teaching hospital over a 3-year period (2002-2004) who had acute adhesional small bowel obstruction and underwent computed tomography (CT). The primary outcomes that we assessed were conservative management or the need for surgical intervention. We investigated time to physiologic gastrointestinal function recovery as a secondary outcome. We examined independent predictors of surgical intervention in a bivariate analysis using a stepwise logistic regression analysis. RESULTS: Of the 100 patients investigated, we excluded 12. Of the 88 remaining patients, 58 (66%) were managed conservatively and 30 (34%) underwent surgery. Peritoneal fluid detected on a CT scan (n = 37) was associated more frequently with surgery than conservative management (46% v. 29%, p = 0.046, chi(2)). Logistical regression identified peritoneal fluid detected on a CT scan as an independent predictor of surgical intervention (odds ratio 3.0, 95% confidence interval 1.15-7.84). CONCLUSION: The presence of peritoneal fluid on a CT scan in patients with adhesional small bowel obstruction is an independent predictor of surgical intervention and should alert the clinician that the patient is 3 times more likely to require surgery.

The value of level III clearance in patients with axillary and sentinel node positive breast cancer.

BACKGROUND: The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed. OBJECTIVE: To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes. METHODS: From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded. RESULTS: Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease. CONCLUSION: Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.

Analysis of patients with false negative mammography and symptomatic breast carcinoma.

AIM: False-negative mammograms may result in a delay in breast carcinoma diagnosis and have important implications for patient care. In this study, the characteristics of symptomatic patients with false-negative mammograms were analysed. METHODS: Patients with symptomatic breast carcinoma were identified over a 10-year period (1994-2004). One hundred and twenty-four patients had false-negative preoperative mammograms and 1241 patients had abnormal preoperative mammograms. Clinical presentation, diagnostic methods and pathology were analysed. False-negative mammograms were reviewed by a specialist breast radiologist. RESULTS: Following retrospective review, 42% of false-negative mammograms were re-categorised as suspicious. The most commonly misinterpreted lesion was architectural distortion/asymmetrical density. Adjuvant ultrasound, where performed (n = 27), raised the level of suspicion in 93% of cases. Patients with false-negative mammograms were more likely to be younger (P < 0.0001), present with nipple discharge (P = 0.002) and have smaller tumours (P < 0.0001). Their tumours were more frequently located outside the upper outer quadrant (P = 0.002). False-negative mammography led to a delay in diagnosis of >2 months in 12 patients. CONCLUSION: Symptomatic patients with false-negative mammograms often demonstrate definite abnormalities on imaging, the most common of which is architectural distortion/asymmetrical density. Those at particular risk were younger patients, those with nipple discharge, and patients with lesions located outside the upper outer quadrant.

Factors affecting successful breast conservation for ductal carcinoma in situ.

BACKGROUND: Successful breast-conserving therapy in DCIS is restricted by high rates of residual disease resulting in the need for radiotherapy and/or re-excision. This study identifies patients with DCIS who are most at risk of compromised margins and of residual disease. METHODS: All patients undergoing breast-conserving surgery for DCIS over a 6-year period were included. Method of diagnosis, mammographic size, pathological size, DCIS-margin distance and residual disease on re-excision were analysed. RESULTS: One hundred and thirty-five patients underwent initial breast-conserving surgery for DCIS. The compromised margin rate was 72%, and the rate of residual disease on re-operation was 54%. On univariate analysis, underestimation of pathological size by mammography by >1 cm occurred in 40% of those with compromised margins undergoing a therapeutic operation compared to only 14% of those with clear margins (P = 0.02). However, on multivariate analysis only pathological size (P < 0.0001, OR = 1.0,95% CI 1.037-1.128) and lack of a preoperative diagnosis by core biopsy (P < 0.0001, OR = 5.3,95% CI 1.859-15.08) were predictive of compromised margins. The presence of residual disease on re-excision was associated with increasing pathological size (P < 0.0001, OR = 1.085,95% CI 1.038-1.134) and decreasing DCIS-margin distance (P = 0.03, OR = 6.694,95% CI 1.84-37.855). Twenty-nine percent (n = 13/45) of lesions < or =3 cm compared to 84% (n = 27/32) of lesions >3 cm had residual disease on re-operation (P < 0.0001). Residual disease was present in 62% (n = 34/55), 64% (n = 7/11) and 17% (n = 2/12) of patients with DCIS-margin distances < or =1, 1-2 and 2-5 mm, respectively. CONCLUSION: Considerable underestimation of DCIS extent by mammography occurs in a high proportion of patients with compromised margins in breast conservation. Patients at particularly high risk of residual disease on re-excision are those with lesions >3 cm and those with DCIS-margin distances of < or = 2mm.

ADAM-17 expression in breast cancer correlates with variables of tumor progression.

The ADAMs are a family of membrane proteins possessing a disintegrin and metalloprotease domain. One of their main functions is shedding of membrane proteins. The aim of this study was to test the hypothesis that ADAM-17 (also known as tumor necrosis factor-alpha converting enzyme) is involved in breast cancer progression. Overexpression of ADAM-17 in MCF-7 breast cancer cells increased in vitro invasion and proliferation, whereas down-regulation of ADAM-17 expression in MDA-MB-435 cells decreased invasion and proliferation. At both mRNA and protein levels, ADAM-17 expression was significantly up-regulated in breast cancer compared with normal breast tissue. Using Western blotting, ADAM-17 protein in breast cancer was shown to exist in two forms migrating with approximate molecular masses of 100 and 120 kDa. Based on their known molecular mass, these bands were taken to represent the active and precursor forms of ADAM-17, respectively. The proportion of active to total ADAM-17 increased progressively from normal breast tissue to primary breast cancer to lymph node metastases (P = 0.017, Kruskal-Wallis test). In primary cancers, the active form was expressed more frequently in node-positive compared with node-negative tumors (P = 0.034, chi(2) test). Furthermore, in primary carcinomas, both forms of ADAM-17 correlated significantly (Spearman correlation analysis) with levels of urokinase plasminogen activator (precursor form: r = 0.246, P = 0.032, n = 83 and active form: r = 0.428, P = 0.0001, n = 83) and proliferating cell nuclear antigen (precursor form: r = 0.524, P < 0.0001, n = 73 and active form: r = 0.365, P = 0.002, n = 73). Our results support the hypothesis that ADAM-17 is involved in breast cancer progression.

Surgical e-learning: validation of multimedia web-based lectures.

BACKGROUND: Distance learning has been advocated increasingly as a modern efficient method of teaching surgery. Efficiency of knowledge transfer and validity of web-based courses have not been subjected to rigorous study to date. METHODS: An entirely web-based surgical 5-week lecture course was designed. Fifty per cent of the lectures were prepared as HTML slides with voice-over while the other group was presented in the text-only form. Only written material presented was examined. The lectures were presented via an educational web module. The lecture series was balanced specifically to reduce the pre-existent knowledge bias. Web usage was estimated utilising surrogates, including the number of hits as well as log-on timing. Face validity was assessed by a standardised questionnaire. RESULTS: Eighty-eight students took part in the lecture series and subsequent examination and questionnaire. Median multiple choice questionnaire (MCQ) marks were significantly higher in the aural lecture-derived stems versus the non-aural (P = 0.012, Mann-Whitney U-test). There was widespread approval of web-based learning as an adjunct to conventional teaching. Usage rates were augmented significantly in the final week when compared to the previous 4 weeks (mean total hits weeks 1-4 +/- SEM: 100.9 +/- 9.7 and mean total hits week 5: 152.1 +/- 13.1; P < 0.001, Kruskal-Wallis). However, total hits did not correlate with overall examination results (r(2) = 0.16). The aural lectures demonstrated higher face validity than the non-aural for content and presentation (P < 0.05, Kruskal-Wallis). CONCLUSIONS: The addition of aural files to the novel web-based lecture series is face valid and results in significantly increased examination performance.

The accuracy of combined versus largest diameter in staging multifocal breast cancer.

BACKGROUND: Evaluating the size of multifocal breast cancer for staging purposes is problematic. Historically, the largest tumor focus in isolation has been used to stage multifocal disease and determine optimum adjuvant therapy. This study compared multifocal and unifocal breast cancer to determine if multifocal breast cancer presents at a higher stage. STUDY DESIGN: We performed a retrospective review of a prospectively collected database of 328 patients who underwent sentinel lymph node biopsy over a 7-year period. Clinical presentation and histopathologic features of multifocal breast cancer were compared with those of unifocal disease. RESULTS: Fifty-three (16%) patients presented with multifocal disease. Higher tumor grade was observed in the multifocal tumors compared with unifocal tumors (34% versus 20% grade III tumor, multifocal versus unifocal disease; p=0.03). Use of combined tumor focus diameter upstaged (pT status) 18 (34%) patients with multifocal tumors. There was no difference in nodal positivity based on pT status between largest and combined diameter multifocal disease. CONCLUSIONS: Combined tumor diameter in multifocal breast cancer does not correspond with an increase in sentinel node positivity and should not be used for staging purposes.

Use of a panel of novel genes for differentiating breast cancer from non-breast tissues.

Existing serum markers for breast cancer such as CA 15-3, BR 27.29 and CEA lack sensitivity and specificity. The aim of this study was to evaluate the value of new putative breast-specific markers for differentiating breast cancer from non-breast tissues. Expression of mammaglobin A (MGA), B726P, small breast epithelial mucin (SBEM) and MUC1 was measured by RT-PCR. MGA mRNA was detected in 86/162 (60%) breast cancers but in only 1/32 (3%) non-breast tissues; B726P was detected in 44/108 (41%) breast cancers but in none of 20 non-breast tissues, while SBEM was present in 52/103 (51%) breast cancers but in only 1/26 non-breast cancer tissues. In contrast to these novel markers, the established breast cancer marker MUC1 was detected in 72/99 (73%) breast cancers and in 22/32 (59%) of non-breast tissues. Combining MGA with B726P separated breast cancer from non-breast tissue with a sensitivity of 71% and a specificity of 95% while combining MGA with SBEM differentiated breast cancer from non-breast tissues with a sensitivity of 76% and a specificity of 89%. Genes such as MGA, B726P and SBEM that are expressed relatively exclusively in breast tissue are potential new markers for breast cancer.

Lipophilin B: A gene preferentially expressed in breast tissue and upregulated in breast cancer.

Lipophilin B (LPB), which is also known as BU101, is a secretoglobin which exists in vivo as a complex with the mammary-specific protein, mammaglobin A (MGA). The aim of our study was to investigate the expression of LPB in a panel of breast and nonbreast tissues and compare its expression with that of MGA. Using RT-PCR, LPB mRNA was detected in 16/25 (64%) of normal breast specimens, 23/30 (77%) of fibroadenomas, 102/156 (65%) of primary breast cancers and in 8/36 (22%) nonbreast tissues. Levels of expression of LPB mRNA were significantly higher in breast cancers compared to both normal breast tissues (p = 0.02) and nonbreast tissue (p < 0.001). In the primary breast cancers, expression of LPB mRNA was positively correlated with the estrogen receptor (p = 0.045) but inversely related to both tumor grade (p < 0.001) and proliferation rates (p = 0.0345). Compared to MGA, expression of LPB was more sensitive but less specific for breast cancer. Using Western blotting, LPB migrated with an approximate molecular mass of 7-8 kDa, the expected molecular mass of free LPB. Immunohistochemical analysis of breast cancers showed that LPB expression was predominantly confined to the cytoplasm of tumor cells. We conclude that expression of LPB is preferentially but not exclusively restricted to breast tissue. Since LPB was expressed relatively specifically in breast tissue and was significantly upregulated in breast carcinomas, it is a promising candidate biomarker for breast cancer.

Predictive value of breast lesions of "uncertain malignant potential" and "suspicious for malignancy" determined by needle core biopsy.

BACKGROUND: The optimum management of patients whose needle core biopsy (NCB) results are of "uncertain malignant potential" (B3) or "suspicious for malignancy" (B4) is unclear. This study correlates B3 and B4 NCB findings with excision histology to determine associated rates of malignancy. METHODS: All NCBs categorized as B3 or B4 were identified from a series of 3729 NCBs. Results of biopsies were reported as normal/nondiagnostic (B1), benign (B2), uncertain malignant potential (B3), suspicious but not diagnostic of malignancy (B4), or malignant (B5) according to the B classification system. B3 lesions included atypical intraductal epithelial proliferations (AIEPs), lobular neoplasia, papillary lesions, radial scars, and potential phyllodes tumors. Histological concordance between NCB and excision specimen was analyzed. RESULTS: A total of 211 B3 lesions and 51 B4 lesions were identified during the study period. The open biopsy rate after a B3/B4 finding was 86% (n = 226). The overall rate of malignancy for B3 lesions after excision was 21%. The B3 lesion-specific rates of malignancy were 6% for radial scars, 14% for papillomas, 35% for AIEP, and 44% for lobular neoplasia. Of the patients with a B4 categorization, 90% (44 of 49) were diagnosed with carcinoma after surgery. Those that were "suspicious for ductal carcinoma-in-situ" and "suspicious for invasion" correlated accurately with excision findings in 81% and 89% of patients, respectively. CONCLUSIONS: Management of lesions in the B3 categorization must be tailored to the patient because the specific lesion types are associated with highly variable rates of malignancy. A repeat biopsy or a therapeutic wide local excision should be undertaken in lesions with a B4 NCB categorization because such lesions are associated with a particularly high risk of malignancy at excision.

Needle core biopsy in the diagnosis of phyllodes neoplasm.

BACKGROUND: Accurate identification of phyllodes neoplasms without surgical intervention is difficult, reducing the ability to manage "benign" lumps non-operatively and impacting on the open benign biopsy rate. Needle core biopsy is considered to be a highly accurate technique in the diagnosis of breast carcinoma. Its accuracy in the diagnosis of phyllodes neoplasm has not been established. METHODS: A series of 3729 core biopsies performed between January 1999 and July 2005 were examined. All core biopsies followed by surgical excision were identified. Histologic concordance between core biopsy and excision specimen was analyzed. RESULTS: Twenty-three patients had phyllodes neoplasm on excisional biopsy with prior core biopsy findings as follows: phyllodes neoplasm (n=2), "equivocal" for phyllodes neoplasm (n=12), fibroadenoma (n=3), benign (n=6). The false negative rate for phyllodes neoplasm was therefore 39% (n=9/23). Of the total biopsy series, 35 patients had a core biopsy suggesting the possibility of phyllodes neoplasm. Of these, 32% (n=11) were found to be phyllodes neoplasm on excision, 3% (n=1) phyllodes neoplasm with breast carcinoma, 6% (n=2) breast carcinoma, and 3% (n=1) sarcoma. When a preference for phyllodes neoplasm (n=4) was stated on the equivocal core biopsies, excision correlated with the stated preference; this correlation also occurred in 90% (n=9/10) of core biopsies where fibroadenoma was favored. CONCLUSIONS: Needle core biopsy rarely produces a definite preoperative diagnosis of phyllodes neoplasm. A diagnosis of fibroadenoma or equivocal phyllodes neoplasm on core biopsy should not prevent excision if clinical suspicion remains.

The role of major duct excision and microdochectomy in the detection of breast carcinoma.

BACKGROUND: The association of nipple discharge with breast carcinoma has resulted in numerous women undergoing exploratory surgery to exclude malignancy. The aim of this study was to determine whether pre-operative factors can identify those patients that are most at risk of carcinoma. METHODS: All patients over a 14-year period (1991-2005) who had a microdochectomy or subareolar exploration for the evaluation of nipple discharge were assessed. Patient characteristics, pre-operative imaging and pathological findings were analysed. RESULTS: Of the 211 patients included in this study, 116 patients had pathological (unilateral, uniductal serous or bloody) discharge. On excision, 6% (n = 7) of patients with pathological discharge and 2.4% (n = 2) of patients with non-pathological discharge were diagnosed with carcinoma. Overall, major duct excision resulted in the diagnosis of carcinoma in 4.3% (n = 9), ADH/LCIS in 4% (n = 8), papilloma in 39% (n = 83), and duct ectasia or non-specific benign disease in 53% (n = 111) of patients. In the patients determined to have malignancy, 44% (n = 4) were premenopausal. No patient with a non-bloody discharge in the total population analysed (28%; n = 59/211), or in the population with a pathological discharge (21%; n = 24/116) was found to have carcinoma upon excision. CONCLUSION: Microdochectomy or major duct excision performed for nipple discharge resulted in a low rate of malignancy on excision. Conservative management of non-bloody nipple discharge can be considered in patients with no other clinical or radiological signs of malignancy.

Predictors of invasive disease in breast cancer when core biopsy demonstrates DCIS only.

BACKGROUND AND OBJECTIVES: Ductal carcinoma in-situ on core biopsy does not preclude invasive disease within the excision specimen, resulting in the need for further axillary surgery. We sought to identify predictors of invasion when DCIS is present on core biopsy. METHODS: From a database of 895 breast cancer patients, patients with DCIS on core biopsy who had subsequent surgical excision were identified. Their excision pathology and preoperative mammography were correlated with risk of invasion. RESULTS: Patients (93) with a preoperative diagnosis of DCIS on core biopsy were identified. On excision, 31 patients (33%) had invasive carcinoma and 13 patients (14%) had microinvasion. A preoperative finding of calcification only on mammogram was associated with DCIS on excision (P = 0.014), whereas the presence of other mammographic features increased the risk of invasion. Size > or =5 cm on excision pathology was associated with increased risk of invasion (P = 0.002). Forty-eight percent (n = 11/23) of those diagnosed by ultrasound-guided core biopsy had frank invasion on excision compared to 21% (n = 12/57) diagnosed by stereotactic techniques (P = 0.017). CONCLUSION: Mammographic features and tumor size can help predict invasion in patients who have DCIS on core biopsy. Patients who have features other than calcification on mammography or have tumor size > or =5 cm should be considered for a sentinel node biopsy.

Current status of combined hormone replacement therapy in clinical practice.

Approximately 20 million women worldwide use hormone replacement therapy (HRT). Formerly, it was thought to confer beneficial cardiac protection and reduce osteoporosis in addition to relieving the symptoms of menopause. However, many recent trials have contradicted these beliefs. The risk of breast cancer associated with HRT use has been well documented but underestimated. Many recent trials have reported higher than expected breast cancer incidence rates, particularly associated with combined HRT. Although it was believed estrogen conferred cardiac protection and reduced the incidence of myocardial ischemic events and cerebrovascular accidents, the more recent literature indicates that this is not true and that HRT users have a higher risk of cardiac and cerebral events. The role of HRT in clinical practice has been redefined. It is no longer an acceptable form of treatment for most women. The evidence indicates that the use of long-term HRT is no longer clinically justifiable.

A pathologic assessment of adequate margin status in breast-conserving therapy.

BACKGROUND: The definition of a clear margin in breast-conserving therapy is uncertain. The purpose of this study was to correlate the tumor-margin distance of the excision specimen with the presence of residual tumor at reoperation. We also analyzed predictors of compromised margins and of residual disease. METHODS: All patients who underwent breast-conserving therapy for invasive disease from 1999 to 2003 were reviewed. Pathologic characteristics and the precise tumor distance from the radial margin were recorded. A radial margin was compromised if invasive or (ductal) in situ carcinoma was <5 mm from the margin. RESULTS: Of the 612 patients who underwent breast conservation, 211 (34%) had compromised margins, and 39 had undetermined margins. Of the 161 patients who had a reoperation for compromised margins, 87 (54%) had residual disease. Residual disease after reoperation was present in 58% (56 of 96), 56% (9 of 16), and 45% (22 of 49) of those with tumor-margin distances <1 mm, > or =1 and <2 mm, and > or =2 and <5 mm, respectively. There was a progressive decline in residual disease for each millimeter until a rate of 22% for tumor-margin distances of > or =4 mm and <5 mm was reached. Pathologic size (P = .004), an extensive intraductal component (P = .002), referral from a symptomatic rather than a population-based screening program (P = .02), and the absence of a preoperative diagnosis by core biopsy (P < .0001) were predictive of compromised margins. Only young age (<45 years) was predictive of finding residual disease on reoperation (P = .02). CONCLUSIONS: A total of 45% of patients who had tumor 2 to 5 mm from the radial margin had residual disease on reoperation. Our results support a policy of requiring a 5-mm margin in patients undergoing breast-conserving therapy for invasive disease.