Morbidity and Mortality Following Breast Cancer Surgery
National Benchmarks for Standards of Care
Mahmoud B. El-Tamer, MD, FACS,* B. Marie Ward, MD,† Tracy Schifftner, MSc,‡
Leigh Neumayer, MD, FACS,§ Shukri Khuri, MD, FACS,? and William Henderson, PhD‡
Background: Most reports on postoperative (OP) morbidity and
mortality following breast cancer surgery (BCS) are limited by
relatively small sample size resulting in a lack of national bench-
marks for quality of care. This paper reports the 30-day morbidity
and mortality following BCS in women using a large prospective
Methods: The National Surgical Quality Improvement Program
Patient Safety in Surgery, prospectively collected inpatient and
outpatient 30 day postoperative morbidity and mortality data on
patients undergoing surgery at 14 university and 4 community
centers. Using the procedure CPT code, the database was queried for
all women undergoing mastectomy (MT) or lumpectomy with an
axillary procedure (L-ANP). Morbidity and mortality were catego-
rized as mortality, wound, cardiac, renal, pulmonary, and central
nervous system. Logistic regression models for the prediction of
wound complications were developed. Preoperative variables having
bivariate relationships with postoperative wound complications with
P ? 0.20 were submitted for consideration.
Results: We identified 1660 and 1447 women who underwent MT
and L-ANP, respectively. The mean age was 55.9 years. The major-
ity of procedures were under general anesthesia. The 30-day post-
operative mortality for MT and L-ALNP were 0.24% and 0%,
respectively. The most frequent morbid complication was wound
infection, more commonly occurring in the mastectomy (4.34%)
group versus the lumpectomy group (1.97%). Cardiac and pulmo-
nary complications occurred infrequently in the mastectomy group
(cardiac: MT, 0.12%; and pulmonary: MT, 0.66%). There were no
cardiac or pulmonary complications in the lumpectomy group. CNS
morbidities were rare in both surgical groups (MT, 0.12%; and
L-ALNP, 0.07%). Development of a UTI was more common in
women who underwent a mastectomy (0.66%) when compared with
women that had a lumpectomy (0.14%). The only significant pre-
dictors of a wound complication were morbid obesity (BMI ?30),
having had a MT, low preoperative albumin and hematocrit greater
Conclusion: Morbidity and mortality rates following BCS in
women are low, limiting their value in assessing quality of care.
Mastectomy carries higher complication rate than L-ANP with
wound infection being the most common.
(Ann Surg 2007;245: 665–671)
dures is considered to be low. The mortality of breast surgical
procedures is reportedly less than 1%.1Surprisingly, the
literature is sparse concerning the perioperative mortality and
morbidity following breast cancer surgery. The few available
reports are retrospective in nature and limited by small
Complications, more frequently associated with general
surgical procedures and prolonged hospital stays, such as
cardiopulmonary and cerebrovascular accidents, have infre-
quently been investigated in patients following breast sur-
gery, albeit secondary to their rare occurrence. The most
frequently cited complications are related to wound infection
and seroma formation. Incidence rates for postoperative
wound infections are variable and range from 3% to 19%.3
Surgical wound infections following breast surgery are not
uncommon and can result in further medical and surgical
interventions, which may warrant prolonged hospitalization
and outpatient follow-up. Moreover, compromise of the cos-
metic outcome and psychologic burden of a surgical site
infection after breast surgery are important considerations,
which support the need for further clinical inquiry.
The objective of the current study was to investigate the
30-day morbidity and mortality rates following breast cancer
surgery in women and define significant predictors of adverse
outcomes and their relative importance.
he cornerstone of breast cancer management is surgical.
The complication rate following breast surgical proce-
From the *New York Presbyterian Hospital at Columbia University Depart-
ment of Surgery, New York, NY; †Long Island Jewish Medical Center-
North Shore University Hospital, Long Island, NY; ‡NSQIP University
of Colorado Health Outcomes Program, Aurora, CO; §George E. Whalen
Salt Lake City Veterans Affairs Health Care System and the Department
of Surgery, University of Utah, Salt Lake City, UT; and ?VA Boston
Healthcare System, Brigham and Women’s Hospital, and Harvard Med-
ical School, Boston, MA.
Supported by Grant No. 1U18HS11913-03 from the Agency for Healthcare
Research and Quality.
Reprints: Mahmoud El-Tamer, MD, FACS, Atchley Pavilion, 10th Floor, 161
Copyright © 2007 by Lippincott Williams & Wilkins
Annals of Surgery • Volume 245, Number 5, May 2007
with other factors. Albumin level, hematocrit, and BMI are
more important for wound healing and immune defense
mechanism; these factors may also be a surrogate to comor-
bid conditions that in a multivariate analysis outweigh the
factor of chronologic age.
Our study is consistent with others, demonstrating that
mastectomy carries a higher morbidity particularly wound
complications, and possibly mortality when compared with
breast preservation. Similarly, our study suggests that pa-
tient’s overall health status (ie, albumin, hematocrit, BMI)
can place a patient at higher risk for wound infections,
thereby providing an opportunity to consider prophylactic
antibiotics in this select group Even so, breast cancer surgery
carries a very low mortality and morbidity rate. Hence, the
standard NSQIP measurement of quality of care in general
surgery, risk-adjusted morbidity and mortality, may be diffi-
cult to apply to breast cancer surgery when comparing per-
formance between different centers due to the very low
number of events. Quality of care in breast cancer surgery
perhaps ought to be measured with survival and local control
of the disease as well as timeliness and appropriateness of
care as preoperative diagnosis, frequency of breast preserva-
tion, false-negative rate of sentinel nodes, appropriate deliv-
ery of chemotherapy, radiation, and endocrine therapy.
Hospitals contributing cases include the following:
Barnes-Jewish Hospital, Brigham & Women’s Hospital,
Emory University Medical Center, Massachusetts General
Hospital, New York Presbyterian Hospital-Columbia Univer-
sity, New York Presbyterian Hospital-Cornell Weil Medical
College, St. Louis University, University of California San
Francisco, University of Florida Gainesville, University of
Kentucky Chandler Medical Center, University of Maryland,
University of Michigan Health System, University of Utah
Health Science Center, University of Virginia Health System,
Community hospitals from the Partners Health Care System:
Newton-Wellesley Hospital, Faulkner Hospital, Salem Hos-
pital, and Union Hospital.
1. Hynes DM, Weaver F, Morrow M, et al. Breast cancer trends and
outcomes: results from a National Department of Veterans Affairs
Study. J Am Coll Surg. 2004;198:707–716.
2. Vinton AL, Traverso LW, Jolly PC. Wound complications after modi-
fied radical mastectomy compared with tylectomy with axillary lymph
node dissection. Am J Surg. 1991;161:584–587.
3. Roststein C, Ferguson R, Cumming KM, et al. Determinants of clean
surgical wound infections for breast procedures at an oncology center.
Infect Control Hosp Epidemiol. 1992;13:207–214.
4. Nieto A, Lozano M, Moro MT, et al. Determinants of wound infections
after surgery for breast cancer. Zentralbl Gynakol. 2002;124:429–433.
5. Yanik R, Wesley MN, Ries LAG, et al. Effect of age and comorbidity in
postmenopausal breast cancer patients aged 55 years and older. JAMA.
6. Eagle KA, Rihal CS, Mickel M, et al. Cardiac risk on noncardiac
surgery: influence of coronary disease and type of surgery in 3368
operations. Circulation. 1997;96:1882–1887.
7. Khuri SF, Daley J, Henderson W, et al. The National Veterans Affairs
Surgical Risk Study: risk adjustment for the comparative assessment of
the quality of surgical care. J Am Coll Surg. 1995;180:519–531.
8. Lemeshow S, Hosmer DW. A review of goodness of fit statistics for use
in the development of logistic regression models. Am J Epidemiol.
9. Webster C, Neumayer L, Smout R, et al. Prognostic models of abdom-
inal wound dehiscence after laparotomy. J Surg Res. 2003;109:130–137.
10. Longo WE, Virgo KS, Johnson FE, et al. Mortality after colectomy for
colon cancer. Dis Colon Rectum. 2000;43:83–91.
11. Beatty D, Robinson GV, Zaia JA, et al. A prospective analysis of
nosocomial wound infection after mastectomy. Arch Surg. 1983;118:
12. Chen J, Gutkin Z, Bawnik J. Postoperative infections in breast surgery.
J Hosp Infec. 1991;17:61–64.
13. Lucci A, Shoher A, Sherman M, et al. Assessment of the current
medicare reimbursement system for breast cancer operations. Ann Surg
14. Seigal BM, Mayzel KA, Love SM. Level I and II axillary dissection in
the treatment of early-stage breast cancer: an analysis of 259 consecutive
patients. Arch Surg. 1990;125:1144–1147.
15. Gibbs J, Cull W, Henderson W, et al. Preoperative serum albumin level
as a predictor of operative mortality and morbidity: results from the
National VA Surgical Risk Study. Arch Surg. 1999;134:36–42.
16. Wattanakit K, Folsom AR, Chambless LE, et al. Risk factors for
cardiovascular event recurrence in the Atherosclerosis Risk in Commu-
nities (ARIC) study. Am Heart J. 2005;149:606–612.
Annals of Surgery • Volume 245, Number 5, May 2007 Complications in Breast Cancer Surgery
© 2007 Lippincott Williams & Wilkins