Refining Lumpectomy for Breast Cancer: Surgeon-Performed Intraoperative Localization and its Patient-Centric Impact

Introduction:

Breast cancer screening through mammography plays a key role in identifying early-stage breast cancer, with over 2/3 of women opting for lumpectomy as their surgical treatment. However, the traditional two-stage process involving preoperative tumor localization by radiology adds complexity and discomfort to patients. Surgeon-performed intraoperative ultrasound-guided localization, or IOL, is a transformative, patient-centric, surgical innovation whereby a surgeon skilled in ultrasound performs the localization themselves at the time of lumpectomy. IOL spares the patient an additional, painful, costly, and inconvenient intervention, and is gaining traction amongst breast surgeons who perform ultrasound. This transformative approach streamlines patient care and empowers patients to seek second opinions from ultrasound-skilled surgeons.

The Challenge:

The conventional lumpectomy process often necessitates a separate radiology procedure for tumor localization with image-guidance, posing additional hurdles to patients. There is another way, however, for many patients to skip this step if their surgeon has sufficient ultrasound skills and can localize the cancer themselves with surgeon-performed intraoperative ultrasound localization (IOL). Many breast surgeons however lack ultrasound skill and are unable to perform this procedure themselves, subjecting patients to additional interventions that can be painful, inconvenient, and costly.  Unfortunately, newly diagnosed breast cancer patients are often unaware of alternatives and fail to seek second opinions from ultrasound-skilled surgeons.

The IOL Advantage:

IOL presents a paradigm shift, allowing breast surgeons with ultrasound skills to perform localization during lumpectomy, eliminating the need for an extra awake, inconvenient procedure.  IOL enhances surgical targeting, tissue resection, and the overall patient experience, simplifying the surgical journey.

  1. Convenience:
    • Shifting from pre-operative, radiology-based tumor localization to intraoperative, surgeon performed IOL combines both localization and tumor resection into a single session, enhancing patient experience.
    • Eliminating an extra step improves surgical scheduling, expedites care, and optimizes treatment timelines.
  2. Patient Discomfort:
    • Traditional, radiology-based localization requires patients to be awake, resulting in pain and discomfort.
    • IOL allows patients to avoid this unpleasant step, performed directly by the surgeon during breast cancer surgery.
  3. Cost-Effectiveness:
    • Radiology-based tumor localization incurs extra cost and inconvenience for patients.
    • IOL, coupled with surgical resection, minimizes financial impact making it a cost-effective choice.  
    • Newer, more expensive wireless localization devices used by surgeons not skilled in ultrasound are notably more expensive to health care systems ($400 per device vs $20-$30 for same-day wires) and often require patients to undergo a procedure with radiology on a separate day of their surgery. 
    • Requiring patients to have procedures on two days, for the localization and then for the surgery, can have impact on potential loss of income and/or childcare for two days instead of only one day for IOL performed at time of surgery

Empowering Patients with Knowledge

Newly diagnosed breast cancer patients are often facing overwhelming stressors in managing their diagnosis, sharing the news with their family and colleagues, and navigating treatment steps.  Many patients are unaware of surgical options and don’t realize they can avoid an extra intervention by radiology.  It is paramount for patients to be informed of IOL and to seek a second opinion with a breast surgeon skilled in ultrasound.  Patients can then feel empowered to make informed decisions about their treatment journey that align with their values.

Educational Initiatives

IOL is an important surgical tool that we want more surgeons to learn and adopt. As such, we are teaching our residents, fellows, and breast faculty how to perform this simple, yet groundbreaking technique to best serve our patients.   By sharing these skills with our future surgeons, we aim to inspire them to perform IOL for their future patients with breast cancer and improve the practice of breast cancer surgery.

Limitations of IOL

While IOL effectively targets many early-stage breast cancers, some findings may not be amenable to this approach such as extensive calcifications requiring mammographic targeting or more complex cases requiring bracketing.

Conclusion

Surgeon performed intraoperative ultrasound guided localization is a transformative technique in breast cancer surgery.  The benefits of convenience, comfort, and cost-effectiveness make IOL an optimal choice for patients with early-stage breast cancer who choose lumpectomy.  As we continue to integrate this technique into practice and train of the next generation of breast surgeons, we hope to pave the way for IOL to become standard of care, improving the experience of patients with breast cancer worldwide.

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