Current practices and trends of breast-conserving surgery in China: A nationwide cross-sectional survey

Breast cancer is the most frequently diagnosed malignancy in the Chinese female population.[1] Breast-conserving surgery (BCS) has long been established as the cornerstone of early-stage breast cancer treatment, with numerous clinical trials confirming its oncologic equivalence to mastectomy in appropriately selected patients. In developed countries, BCS rates among patients with early-stage breast cancer typically range from 60% to 80%.[2] However, its adoption in China remains relatively low; a national cross-sectional study conducted in 2017 reported an overall BCS rate of only 22%.[3] Therefore, understanding the factors influencing BCS adoption, including institutional and socioeconomic elements, is crucial for improving the standardization of care and enhancing the acceptance of BCS across clinical settings in China. Through a questionnaire survey conducted across 215 hospitals in Chinese Mainland, this study aimed to assess current practices and trends in BCS, identify factors influencing its adoption, and explore the use of oncoplastic techniques and margin assessment strategies. By comparing with the 2017 survey from the same series,[3] the study aims to guide future initiatives to enhance the safety, accessibility, and effectiveness of BCS in China. A standardized questionnaire [Supplementary Material, https://links.lww.com/CM9/C713] was developed to assess current surgical practices for breast cancer treatment in hospitals accredited by the Chinese Anti-Cancer Association’s Committee of Breast Cancer Society (CACA-CBCS) and the Chinese Society of Breast Surgeons (CSBS). It consisted of seven sections: respondent and hospital practices, axillary lymph node surgery, BCS, breast reconstruction, endoscopy-assisted breast surgery, revision procedures, and surgical management of lymphedema. The questions in the BCS section remained largely consistent with the 2017 questionnaire, ensuring comparability between the two surveys. This study did not include specific patient data, human or animal samples. Data are collected from hospital statistics and doctors’ opinions. The Board of Ethical Committee of Fudan University Shanghai Cancer Center (FUSCC) waived the requirement of ethical approval for this research. In the 2017 survey, the standardized questionnaire was distributed to hospitals nationwide that had performed at least 200 breast cancer surgeries. A sampling strategy was employed to enhance the diversity of the participating hospitals, considering their geographic distribution and annual surgical volume. Hospitals were selected across different provinces and surgical volume ranges. This selection method resulted in the inclusion of 110 centers in 2017. In line with the 2017 survey, hospitals were selected based on a similar sampling strategy in 2022. A total of 215 centers were selected. To ensure data reliability, the CACA-CBCS and CSBS notified the directors of these centers, and each department assigned a specialist to complete the questionnaire. By 17 March 2024, 198 centers fully responded to the survey and were included in the analysis. Fully completed questionnaires that were free of logical errors were considered valid. Categorical data were presented as counts and percentages, while continuous data were summarized as medians with interquartile ranges (IQRs) due to their non-normal distribution. For cross-sectional analysis of the 2022 survey data, the Kruskal–Wallis rank sum test was used to compare continuous variables across multiple groups. To evaluate differences between the 2022 and 2017 surveys, the Mann–Whitney U test was applied for continuous variables, and the Chi-squared test was applied for categorical variables. Univariable and multivariable linear regression models were used to explored the factors associated with re-excision rates. All analyses were conducted using SPSS 27.0 (IBM Corp., Armonk, NY, USA) and GraphPad Prism 9.0 (GraphPad Software, San Diego, CA, USA). A value of P less than 0.05 was considered statistically significant. Of the 215 hospitals surveyed in 2022, 198 provided complete responses on BCS, resulting in a 92.1% (198/215) response rate. The surveyed hospitals collectively reported 123,907 breast cancer surgeries, with BCS accounting for 26.6% (32,983/123,907), an increase from 21.9% in 2017. Additionally, the institutional median BCS rate increased from 15.0% (IQR: 15.0–25.0%) in 2017 to 22.0% (IQR: 18.0–30.0%) (P <0.001) in 2022, indicating a notable advancement in BCS adoption. Analysis by cancer stage showed increased BCS rates across all stages, with a statistically significant increase for stage I cancer (P = 0.010), but not for stages 0 (P = 0.780), II (P = 0.122), or III (P = 0.121) [Supplementary Figure 1A, https://links.lww.com/CM9/C713]. Despite this progress, BCS rates varied substantially across institutions [Supplementary Figure 1B, https://links.lww.com/CM9/C713]. The presence of qualified plastic surgeons was associated with higher BCS rates (median 25.0% vs. 20.0%, P = 0.034) [Supplementary Table 1, https://links.lww.com/CM9/C713]. Although not statistically significant, hospitals with a greater breast surgical volume (median 40.0% vs. 20.0%, P = 0.243) and more breast surgeons (median 35.0% vs. 25.0%, P = 0.211) also had a higher BCS rate. However, factors such as hospital region and high per capita GDP showed no association with BCS rates. The survey revealed a median BCS rate of 20.0% (IQR: 10.0–30.0%) following neoadjuvant therapy in 2022, an increase from 5% (IQR: 5–15%) in 2017. In 22% of the hospitals surveyed, BCS was performed in more than 30.0% of the patients who underwent neoadjuvant therapy [Supplementary Figure 1C, https://links.lww.com/CM9/C713], whereas only 15% of the hospitals achieved this in 2017. None of those above key factors were significantly associated with the BCS rate following neoadjuvant therapy [Supplementary Table 1, https://links.lww.com/CM9/C713]. We then examined the methods used for evaluating surgical margins in BCS across different institutions. Tangential shaved margins remained the predominant choice for pathological sampling (66.2%, 131/198) [Supplementary Figure 2A, https://links.lww.com/CM9/C713]. However, the adoption of perpendicular inked margins had increased compared to 2017 (33.8% vs. 25.5%, χ2 = 2.33, P = 0.127). Additionally, approximately 50% of the surveyed hospitals regularly performed margin staining (49.4% in 2022 vs. 24.5% in 2017, χ2 = 18.25, P <0.001) and more than half routinely performed cavity shaving (56.1% in 2022 vs. 31.8% in 2017, χ2 = 16.67, P <0.001) [Supplementary Figures 2B and C, https://links.lww.com/CM9/C713]. For the newly added aspect of pathological evaluation methods, nearly all hospitals favored intraoperative frozen section analysis (92.9%, 184/198) over postoperative paraffin section analysis [Supplementary Figure 2D, https://links.lww.com/CM9/C713]. The median re-excision rate reported in this survey was 6.0% (IQR: 3.0–15.0%), which was considerably higher than the 2.5% (IQR: 2.5–8.0%) reported in 2017. Half (99/198) of the hospitals reported a re-excision rate of 5% or less [Supplementary Figure 2E, https://links.lww.com/CM9/C713]. The implementation of contralateral symmetry procedures was associated with a notably reduced risk of re-excision (odds ratio [OR] = 0.491, 95% CI: 0.264–0.912, P = 0.024) [Supplementary Table 2, https://links.lww.com/CM9/C713]. Conversely, BCS following neoadjuvant chemotherapy was modestly but significantly linked to a higher re-excision rate (OR = 1.029, 95% CI: 1.011–1.048, P = 0.002). In the multivariate model adjusted for variables with clinical relevance (routine margin staining and use of cavity shave margins) and those with statistical significance in univariable analysis (contralateral symmetry procedures and neoadjuvant chemotherapy use), neoadjuvant chemotherapy remained an independent predictor of increased re-excision rates (OR = 1.030, 95% CI: 1.008–1.053, P = 0.007). The use of oncoplastic techniques in BCS showed no significant change between 2017 and 2022 (median 30.0% vs. 30.5%, P = 0.164). However, adoption rates varied widely among hospitals. While 25.8% of hospitals performed oncoplastic surgery (OPS) in >50% of BCS cases, over one-fourth of hospitals (28.8%, 57/198) reported rates of 10% or lower [Supplementary Figure 3A, https://links.lww.com/CM9/C713]. Higher OPS rates were correlated with increased surgical volume (median 40.0% vs. 20.0%, P <0.001), a greater number of breast surgeons (median 35.0% vs. 25.0%, P = 0.035), and routine implementation of contralateral symmetry procedures (median 35.0% vs. 20.0%, P = 0.001) [Supplementary Table 1, https://links.lww.com/CM9/C713]. Among the different oncoplastic techniques used in BCS [Supplementary Figure 3B, C, https://links.lww.com/CM9/C713], the volume displacement technique was considerably more commonly used than the volume replacement technique (median, 70.0% vs. 30.0%, P <0.001), which is consistent with that observed in 2017. Regarding the factors potentially associated with the choice of oncoplastic techniques, statistical analysis revealed that the use of contralateral symmetry procedures was correlated with a higher rate of volume displacement techniques (median 70.0% vs. 51.0%, P = 0.003). This study presents a comprehensive analysis of current BCS practices in China, highlighting the increasing but relatively low rates of BCS. A major contributing factor to this disparity may be the low rate of early-stage breast cancer diagnosis, which contributes to a higher proportion of mastectomies. A recent global meta-analysis reported that only about 60% of breast cancers in China are diagnosed early for stages I and II, compared to approximately 90% in the United States.[4] Cultural conservatism also plays a role, as many Chinese patients are reluctant to choose BCS due to concerns of local recurrence. Addressing these challenges through improved patient education and stronger doctor–patient communication may help increase the acceptance and adoption of BCS. Neoadjuvant therapy for early-stage breast cancer can increase the feasibility of BCS. In our cohort, BCS rates following neoadjuvant therapy strongly correlated with overall BCS rates. Multiple studies have reported that, compared to patients undergoing direct surgery, those receiving neoadjuvant therapy may have a slightly higher risk of local recurrence; however, this does not appear to negatively impact long-term patient survival.[5] Therefore, optimizing patient selection and evaluation and refining tumor bed localization are critical during the perioperative period for patients undergoing neoadjuvant therapy. Effective pathological assessment of surgical margins is essential to the safety and success of BCS. Since 2017, our study has reported increased adoption of perpendicular inked margins, routine use of margin staining, and cavity shaving. International guidelines consistently recommend the “no ink on tumor” standard to define negative margins. However, a recent meta-analysis reported that closer margins (less than 2 mm) were associated with a higher risk of local recurrence and distant metastasis.[6] In this context, the adoption of perpendicular inked margins should be emphasized, as it allows for an accurate measurement of the distance between the lesion and the surgical margin. Our study found a median re-excision rate of 6.0%, considerably lower than the 15–20% observed in developed countries. This difference may reflect the use of stricter criteria and broader excision scope in China. Univariate and multivariate logistic regression analyses revealed neoadjuvant therapy as a risk factor for re-excision, possibly due to non-concentric tumor shrinkage after neoadjuvant therapy. Therefore, reliable imaging examinations to evaluate tumor regression patterns and the extent of response to neoadjuvant therapy may help reduce re-excision rates. Oncoplastic BCS combines oncologic surgical techniques with plastic surgery methods to restore the breast shape while ensuring oncological safety. Our survey revealed that the overall adoption rate of OPS in 2022 remained largely unchanged from 2017, with substantial variability across hospitals. OPS can be categorized into two main types: volume displacement and volume replacement. Our study indicated that volume displacement remained the predominant oncoplastic approach in China, although the use of volume replacement techniques had increased since 2017. The prevalence of volume displacement techniques may be due to their relative ease of implementation, particularly in centers with limited oncoplastic resources. Nonetheless, the choice between these techniques should be individualized, as both offer distinct advantages depending on the clinical scenario. This study has certain limitations. First, its questionnaire-based design introduces potential response bias, which may affect the accuracy and generalizability of the findings. Second, the cross-sectional nature of the study precludes the establishment of causal relationships between hospital characteristics and surgical outcomes. Third, the absence of patient-level data limits evaluation of the safety and effectiveness of the reported practices. Future research employing longitudinal, patient-based cohorts is needed to offer a more comprehensive understanding. Despite these limitations, this study offers a comprehensive analysis of BCS practices in China, highlighting an overall increase in BCS adoption, particularly following neoadjuvant therapy. While the evaluation of pathological margins is becoming more standardized, interhospital variability persists. OPS rates showed minimal change over 5 years, with oncoplastic resource allocation potentially limiting its development. Further research is needed to assess the long-term impact of current surgical practices and optimize patient outcomes. Acknowledgment We acknowledge the staff of the CBCS and CSBS working groups for their support in participant recruitment and data collection. Funding This study was supported by the Shanghai Academic Research Leader Program (No. LJRC2202) and the Science and Technology Commission of Shanghai Municipality (No. KW2234). Conflicts of interest None.