Comparing oncoplastic breast conserving surgery with mastectomy and immediate breast reconstruction: Case-matched patient reported outcomes

Oncoplastic reconstruction with breast-conserving treatment versus breast-conserving treatment alone in the elderly

BACKGROUND/OBJECTIVES

Oncoplastic reconstruction (IOR) performed in conjunction with breast conserving therapy (BCT) has been found to improve psychosocial well-being, reduce hospitalization time, and reduce cost burden. Few studies have looked at the safety profile, complication rates, and overall outcomes in patients ages 65 years and older undergoing IOR versus BCT alone.

METHODS

A retrospective, cross-sectional, single-institution medical record review was conducted of women diagnosed with breast cancer age 65 years or older who received IOR or BCT alone. Demographics, clinical data, and major and minor complication profiles were compared between cohorts.

RESULTS

A total of 310 patients were included. Of these, 126 received IOR, while 184 received BCT alone. Age >85 was found to have a significantly higher risk for any complication and was an independent predictor for experiencing any complication (OR: 8.5, p = 0.015; OR: 1.06, p = 0.029). Major complication rates were significantly higher in the BCT cohort (16.9% vs. 7.9%, p = 0.023).

CONCLUSION

IOR in the elderly is a safe option and was not found to be a predictor of experiencing higher complications. Patients who are 85 years and older had a higher risk of complications, and future studies may explore risk-benefit in that particular cohort of patients in which BCT is planned.

Immediate Symmetrization of the Contralateral Breast in Breast Reconstruction-Revision, Complications, and Satisfaction: A Systematic Review

Background

It is desirable to achieve breast symmetry after unilateral surgery for breast tumors. Thus, contralateral balancing is often required, but it is still debated whether symmetrization surgery should be performed alongside reconstruction or as a delayed procedure. Therefore, we aimed to compare revision rates, complication rates, and satisfaction levels between those who underwent immediate versus delayed symmetrization.

Methods

A systematic review was designed to summarize the revision surgery rates, complication rates, and satisfaction levels of patients who underwent contralateral breast symmetrization at the same time as breast reconstruction. We included articles published between 2010 and 2022 in databases such as PubMed, MEDLINE, and Embase.

Results

Most studies showed no difference or lower revision rates for immediate symmetrization, except for one study where immediate symmetrization had a revision rate twice that of delayed symmetrization. There were no significant differences in complication rates between the two groups. Regarding satisfaction levels, most studies showed that the immediate group had higher scores regardless of statistical significance; however, breast-related satisfaction was significantly higher in the immediate group than in the delayed group.

Conclusion

This systematic review demonstrates that immediate symmetrization surgery does not increase revision surgery and complication rates or decrease satisfaction levels.

Long-Term Patient-Reported Outcomes Comparing Oncoplastic Breast Surgery and Conventional Breast-Conserving Surgery: A Propensity Score-Matched Analysis

INTRODUCTION

Oncoplastic breast surgery (OBS) combines plastic surgery techniques with conventional breast-conserving surgery (BCS) and expands BCS eligibility. Limited data are available on patient-reported outcomes (PROs) after OBS. Here we compare long-term PROs after OBS and BCS utilizing the BREAST-Q.

PATIENTS AND METHODS

Women undergoing OBS or BCS between 2006 and 2019 who completed ≥ 1 long-term BREAST-Q survey 3-5 years postoperatively were identified. Baseline characteristics were compared between women who underwent OBS/BCS. Women who underwent OBS were paired with those who underwent BCS using 1:2 propensity matching [by age, body mass index (BMI), race, T stage, and multifocality]. BREAST-Q scores were compared preoperatively and 3-5 years postoperatively.

RESULTS

A total of 297 patients were included for analysis (99 OBS/198 BCS). Women who underwent OBS were younger (p < 0.001) and had higher BMI (p = 0.005) and multifocal disease incidence (p = 0.004). There was no difference between groups in nodal stage, re-excision rates, axillary surgery, chemotherapy, endocrine therapy, or radiotherapy. After propensity matching preoperatively, women who underwent OBS reported lower psychosocial well-being (63 versus 100, p = 0.039) but similar breast satisfaction and sexual well-being compared with women who underwent BCS; however, only three patients who underwent BCS had preoperative BREAST-Q scores available for review. In long-term follow-up, women who underwent OBS reported lower psychosocial scores (74 versus 93, p = 0.011) 4 years postoperatively, but not at 5 years (76 versus 77, p = 0.83). There was no difference in long-term breast satisfaction or sexual well-being.

CONCLUSIONS

Women who undergo OBS present with a larger disease burden and may represent a group of non-traditional BCS candidates; they reported similar long-term breast satisfaction and sexual well-being compared with women who undergo BCS. While women who underwent OBS reported lower psychosocial well-being scores preoperatively and during a portion of the follow-up period, this difference was no longer seen at 5 years postoperatively.

Aesthetic results were more satisfactory after oncoplastic surgery than after total breast reconstruction according to patients and surgeons

INTRODUCTION

Patient satisfaction after breast cancer surgery has an impact on body image, sexual function, self-esteem, and quality of life and may differ from the perception of the attending physician. This study aimed to compare the aesthetic outcomes and satisfaction with conservative oncoplastic surgeries, mastectomies, and total breast reconstruction.

METHODS

We included 760 women diagnosed with invasive breast carcinoma or phyllodes tumors who returned at least 6 months after surgery or radiotherapy at two public hospitals and a private clinic between 2014 and 2022. Data was collected prospectively from patients and retrospectively from their medical records using a specific form after obtaining their informed consent. Aesthetic outcomes and quality of life were assessed using the BREAST-Q©, Harris Scale, and BCCT.core software. Data were evaluated using the SPSS statistical software. Statistical significance was set at p < 0.05. This study was approved by the hospital ethics committees.

RESULTS

A total of 405 (53.29%) partial and 355 (46.71%) total reconstructions were included. Patients who underwent partial reconstruction were older and had higher body mass index. Patients who underwent total reconstruction had larger tumors with advanced clinical and pathological stages. Clinical and surgical complications occurred more frequently in the total reconstruction group. A greater number of reparative surgeries and lipofilling procedures were required for total reconstruction. According to the BREAST-Q, the partial reconstruction group showed significantly higher levels of women's satisfaction with their breasts, the surgical outcomes, psychosocial and sexual well-being, provision of information, and the reconstructive surgeon. Only physical well-being was slightly higher in the total reconstruction group. In most cases, the results were rated good or excellent. Physicians considered partial reconstructions to have better results than total reconstructions, although this difference was not perceived by the BCCT.core software.

CONCLUSION

Women who underwent partial breast reconstruction had higher levels of satisfaction in several domains, lower frequency of complications, and required fewer surgeries to complete their reconstruction than women who underwent total reconstruction. Physicians were also more satisfied with the results of partial reconstructions.

Surgeon Factors Influencing Breast Surgery Outcomes: A Scoping Review to Define the Modern Breast Surgical Oncologist

BACKGROUND

Modern breast surgical oncology incorporates many aspects of care including preoperative workup, surgical management, and multidisciplinary collaboration to achieve favorable oncologic outcomes and high patient satisfaction. However, there is variability in surgical practice and outcomes. This review aims to identify modifiable surgeon factors influencing breast surgery outcomes and provide a definition of the modern breast surgical oncologist.

METHODS

A systematic literature search with additional backward citation searching was conducted. Studies describing modifiable surgeon factors with associated breast surgery outcomes such as rates of breast conservation, sentinel node biopsy, re-excision, complications, acceptable esthetic outcome, and disease-free and overall survival were included. Surgeon factors were categorized for qualitative analysis.

RESULTS

A total of 91 studies met inclusion criteria describing both modifiable surgeon factor and outcome data. Four key surgeon factors associated with improved breast surgery outcomes were identified: surgical volume (45 studies), use of oncoplastic techniques (41 studies), sub-specialization in breast surgery or surgical oncology (9 studies), and participation in professional development activities (5 studies).

CONCLUSIONS

On the basis of the literature review, the modern breast surgical oncologist has a moderate- to high-volume breast surgery practice, understands the use and application of oncoplastic breast surgery, engages in additional training opportunities, maintains memberships in relevant societies, and remains up to date on key literature. Surgeons practicing in breast surgical oncology can target these modifiable factors for professional development and quality improvement.

How breast cancer therapies impact body image - real-world data from a prospective cohort study collecting patient-reported outcomes

BACKGROUND

In breast cancer patients body image (BI) is a crucial aspect of quality of life (QoL). This study examined the postoperative impact of different surgical approaches on long-term BI analyzing real-world data to guide pre- and postoperative patient care and preserve QoL.

METHODS

EORTC QLQ-BR23 BI scores were collected electronically in 325 breast cancer patients within routine clinical care for a duration of 41.5 months (11/17/2016 - 4/30/2020) at predefined time points preoperatively and repeatedly up to two years after breast-conserving surgery (BCS) (n = 212), mastectomy alone (M) (n = 27) or mastectomy with immediate breast reconstruction (MIBR) (n = 86). Higher scores indicated better BI. A linear mixed regression model was used to analyze the impact of BCS, M and MIBR, as well as non-surgical therapies on BI at treatment initiation and over time.

RESULTS

BI scores deteriorated by 5 points (95%-confidence interval (CI) -8.94 to -1.57, p≈0.005) immediately after BCS, by 7 points (95%-CI -12.13 to -1.80, p≈0.008) after MIBR and by 19 points (95%-CI -27.34 to -10.34, p < 0.001) after M. The change over time after BCS (+ 0.10 points per week, 95%-CI -0.17 to 0.38), MIBR (-0.07 points per week, 95%-CI -0.35 to 0.20) and M (+ 0.14 points per week, 95%-CI -0.19 to 0.48) were not statistically significant (each p > 0.05). At treatment initiation chemotherapy was associated with a 22-point decline (95%-CI -25.39 to -17.87, p < 0.001) in BI score, while radiotherapy was associated with a 5-point increase (95%-CI 1.74 to 9.02, p≈0.004). However, over time chemotherapy was associated with a score recovery (+ 0.28 points per week, 95%-CI 0.19 to 0.37, p < 0.001), whereas for radiotherapy a trend towards BI deterioration was observed (-0.11 points per week, 95%-CI -0.23 to 0.02, p≈0.101).

CONCLUSIONS

Breast cancer surgery negatively affects BI. BCS and MIBR presumably harm BI less than M in the early postoperative period. Our data suggests BI to be deteriorating in the long term after MIBR while improving after BCS or M. Radiotherapy seems to have an additional negative long-term impact on BI. These findings should be confirmed in further studies to enable evidence-based patient information as part of preoperative shared decision-making and postoperative patient care.

Modern Approaches to Oncoplastic Surgical Treatment

Partial breast reconstruction using oncoplastic techniques is performed at the time of lumpectomy and includes volume replacement techniques such as flaps and volume displacement techniques such as reduction and mastopexy. These techniques are used to preserve breast shape, contour, size, symmetry, inframammary fold position, and position of the nipple-areolar complex. Newer techniques such as auto-augmentation flaps and perforator flaps continue to broaden options and newer radiation therapy protocols will hopefully reduce side effects. Options for the oncoplastic approach now include higher risk patients as there is a larger repository of data on the safety and efficacy of this technique.

Sometimes it is better to just make it simple. De-escalation of oncoplastic and reconstructive procedures

Simple breast conservation surgery (sBCS) has technically advanced onto oncoplastic breast procedures (OBP) to avoid mastectomy and improve breast cancer patients' psychosocial well-being and cosmetic outcome. Although OBP are time-consuming and expensive, we are witnessing an increase in their use, even for cases that could be managed with sBCS. The choice between keeping it simple or opting for more complex oncoplastic procedures is difficult. This review proposes a pragmatic approach in assisting this decision. Medical literature suggests that OBP and sBCS might be similar regarding local recurrence and overall survival, and patients seem to have higher satisfaction levels with the aesthetic outcome of OBP when compared to sBCS. However, the lack of comprehensive high-quality research assessing their safety, efficacy, and patient-reported outcomes hinders these supposed conclusions. Postoperative complications after OBP may delay the initiation of adjuvant RT. In addition, precise displacement of the breast volume is not effectively recorded despite surgical clips placement, making accurate dose delivery tricky for radiation oncologists, and WBRT preferable to APBI in complex OBP cases. With a critical eye on financial toxicity, patient satisfaction, and oncological outcomes, OBP must be carefully integrated into clinical practice. The thoughtful provision of informed consent is essential for decision-making between sBCS and OBP. As we look into the future, machine learning and artificial intelligence can potentially help patients and doctors avoid postoperative regrets by setting realistic aesthetic expectations.

Examining a decade of racial disparity in partial mastectomy and oncoplastic surgery

BACKGROUND AND OBJECTIVES

Understanding racial disparity is crucial to addressing health equity and access to care. Our study aims to examine racial differences in breast conserving surgery (BCS) utilization rates and determine how these rates have changed over time.

METHODS

This retrospective cohort analysis utilized the NSQIP database to identify women diagnosed with breast cancer who underwent BCS procedures between 2008 and 2019. Racial utilization trends were analyzed using a Cochran-Armitage test and Index of Disparity analysis.

RESULTS

In the 12-year period, 202 492 women underwent a breast cancer surgery, of which 47% underwent BCS. Within the BCS subgroup, oncoplastic surgery utilization increased from 3% to 10%, leading to a declining proportion of partial mastectomies: 97% to 90.0% (both p < 0.01). The racial index of disparity for overall BCS patients decreased from 7% to 6%, remained unchanged (1%) for partial mastectomies, and significantly decreased in oncoplastics (23%-7.6%).

CONCLUSION

BCS represents a mainstay option for early-staged breast cancer interventions, this study demonstrate promising progress in decreasing the index of disparity among races and persistent racial inequalities.

Single Versus Dual Surgeon Approaches to Oncoplastic Surgery: A Comparison of Outcomes

INTRODUCTION

Oncoplastic surgery (OPS) is traditionally performed using a dual surgeon (DS) approach that involves both a breast surgeon and a plastic surgeon. It is also performed using a single surgeon (SS) approach with a surgeon trained in both breast surgical oncology and plastic surgery. We sought to determine if outcomes differed between SS versus DS OPS approaches.

METHODS

A retrospective chart review was conducted of all OPS performed in a single health system over a 6-y period by either an SS or a DS approach. Primary outcomes were rates of positive margins and the overall complication rate; secondary outcomes were loco-regional recurrence, disease-free survival, and overall survival.

RESULTS

A total of 217 patients were identified; 117 were SS cases and 100 were DS cases. Baseline preoperative patient characteristics were similar between the two groups as there was no difference in mean Charlson Comorbidity Index scores (P = 0.07). There was no difference in tumor stage (P = 0.09) or nodal status (P = 0.31). Rates of positive margins were not significantly different (10.9% (SS) versus 9% (DS); P = 0.81), nor were rates of complications (11.1% (SS) versus 15% (DS); P = 0.42). Rates of locoregional recurrence were also not significantly different (1.7% (SS) versus 0% (DS); P = 0.5). Disease-free survival and overall survival were not significantly different at 1-y, 3-y, and 5-y time points (P = 0.20 and P = 0.23, respectively) although follow-up time was not sufficient for definitive analysis regarding survival.

CONCLUSIONS

Both SS and DS approaches to OPS have similar outcomes with regards to positive margin rates and surgical complication rates and are comparably safe.

Comparison of Body Image and Body Exposure During Sexual Activity and Sexual Assertiveness Among Mastectomized Women with/Without Mammaplasty and Mammaplasty Volunteer Patients

Background: Mastectomy can change body image and affect the sexual activities of patients. Breast reconstruction is a way to reduce the sexual damage caused by mastectomy. Objectives: The present study aimed to compare body image and body exposure during sexual activity and sexual assertiveness among mastectomized women with/without mammaplasty and patients with cancer who volunteered for mammoplasty. Methods: This causal-comparative study was performed on the statistical population of mastectomized women with/without mammaplasty and patients who volunteered for mammoplasty within the age range of 25 - 55 years in Tehran, Iran, in 2018. The sample consisted of 37 women with mastectomy, 28 mastectomized women who volunteered for mammoplasty, and 31 women who underwent mammaplasty after mastectomy. The subjects were selected through convenience sampling in Tehran. All participants were asked to complete the Assessment of Body-Image Cognitive Distortions Questionnaire, the Body Exposure during Sexual Activities Questionnaire, and the Hurlbert Index of Sexual Assertiveness. The data were analyzed by analysis of variance using version 20th of SPSS software. Results: In terms of body-image cognitive distortions, there was no difference between the three groups. The women who underwent mammaplasty had less body exposure during sexual activity than patients who volunteered for mammoplasty (P < 0.01); however, there was no difference between the mastectomized patients and patients who underwent mammaplasty. Exposure to the body or anxious attentional focus on the body during sexual activity was reported frequently less in mastectomized women than in mammaplasty volunteers (P < 0.01). The sexual assertiveness of women who underwent reconstructive surgery was more than mastectomized women and volunteer patients for reconstructive surgery (P < 0.01). The mastectomized group had more sexual assertiveness than patients who volunteered for mammoplasty (P < 0.01). Conclusions: The results support the hypothesis that the issue of body image and its relationship with different aspects of sexual function is complex and requires considering different personality traits and factors as moderators. The importance that a woman places on the breast as a symbol of femininity and sexuality is one of the aforementioned factors. The purpose of reconstruction from the patient’s point of view and the importance that a woman gives to her appearance are other components that should be considered before proceeding with mammoplasty.

Comparing outcomes of single-port insufflation endoscopic breast-conserving surgery and conventional open approach for breast cancer

Background

In the surgical treatment of breast cancer, the goal of surgeons is to continually create and improve minimally invasive surgical techniques to increase patients’ quality of life. Currently, routine breast-conserving surgery is often performed using two obvious incisions. Here, we compare the clinical efficacy and aesthetic outcomes of a novel technique using one incision, called ‘single-port insufflation endoscopic breast-conserving surgery’ (SIE-BCS), vs. conventional breast-conserving surgery (C-BCS) in patients with early-stage breast cancer.

Methods

A total of 180 patients with stage I or stage II breast cancer participated in this study, of whom 63 underwent SIE-BCS and 117 underwent C-BCS. Logistic regression analysis was conducted to assess the risk of local recurrence and metastasis. Aesthetic outcomes were evaluated using the BREAST-Q scale.

Results

The mean operation time was significantly longer for SIE-BCS (194.9 ± 71.5 min) than for C-BCS (140.3 ± 56.9 min), but the mean incision length was significantly shorter for SIE-BCS than for C-BCS (3.4 ± 1.2 cm vs. 8.6 ± 2.3 cm). While both surgeries yielded similar BREAST-Q ratings for satisfaction with breasts and sexual well-being, SIE-BCS was associated with significantly better ratings for physical well-being (chest area) and psychological well-being. Additionally, SIE-BCS was associated with decreased rates of adverse effects of radiation. The preliminary analysis showed that SIE-BCS did not increase the risk of local recurrence or metastasis.

Conclusion

The novel single-port insufflation endoscopic assisted BCS technique is feasible, safe, and improves patients’ postoperative comfort and psychological well-being, as compared to the conventional technique.

The iTOP trial: Comparing immediate techniques of oncoplastic surgery with conventional breast surgery in women with breast cance - A prospective, controlled, single-center study

INTRODUCTION

Oncoplastic techniques allow resection of larger tumors, permitting breast conservation in cases otherwise requiring mastectomy. We sought to prospectively compare quality of life (QoL) in patients undergoing oncoplastic surgery as compared to conventional breast conservation (CBC) or mastectomy is lacking.

METHODS

Patients diagnosed with BIRADS IV-VI lesion were eligible if resection of ≥10% of the breast volume was planned. Patients were allowed to decide whether they wanted to undergo CBC or oncoplastic breast conservation (OBC). Patients who underwent mastectomy and immediate breast reconstruction (IBR) were also included for comparison. The primary endpoint was breast self-esteem using the Breast Image Scale (BIS) at 12 months, secondary endpoints were perioperative morbidity and QoL using the BREAST-Q questionnaire.

RESULTS

From 2011 to 2016, 205 patients were included in the study. 116 patients (56.6%) received CBC, 46 (22.4%) OBC and 43 (21%) MIBR. Women in the OBC group were more likely to have tumors ≥ 2cm than those in the CBC group (34.7% vs. 17.5%, respectively). Women who underwent MIBR were more likely to have tumors > 5cm than those in the CBC and OBC groups (23% vs 1% and 10%, respectively). The BIS and BREAST-Q improved in each group after 12 months but did not differ significantly between groups at any time point. Surgical complications (seroma, bleeding, infection, necrosis) were numerically more likely in the OBC and MIBR groups.

CONCLUSION

OBC and the MIBR allow for resection of larger tumors with a similar quality of life as CBC.

The Impact Oncoplastic Reduction Has on Long-Term Recurrence in Breast Conservation Therapy

BACKGROUND

The use of oncoplastic reduction techniques have many proven benefits over lumpectomy alone in the management of women with breast cancer. The impact it has on tumor recurrence is unclear. The purpose of this review was to evaluate the incidence of recurrence in patients who underwent oncoplastic reduction techniques compared to lumpectomy alone.

METHODS

A prospectively maintained database of patients at Emory Hospital who underwent oncoplastic reduction techniques at the time of tumor resection was queried. These patients were compared to a series of patients who had lumpectomy alone over a similar period. For inclusion in the study, patients were at least 10 years since the time of the tumor resection. The main outcome of interest was tumor recurrence.

RESULTS

There were 97 patients in the lumpectomy-only group and 95 patients in the oncoplastic reduction group, with an average follow-up of 7.8 years and 8.5 years, respectively. Patients in the oncoplastic group were younger (lumpectomy only, 61.4 years; oncoplastic reduction, 51.6 years; p < 0.001) and had larger tumors (lumpectomy only, 1.1 cm; oncoplastic reduction, 1.6 cm; p < 0.001). Local recurrence was 13 percent in the lumpectomy-only group and 9 percent in the oncoplastic reduction group (p = 0.34), and overall recurrence rates were similar (lumpectomy only, 15 percent; oncoplastic reduction, 24 percent; p = 0.13). Overall, surgical intervention (lumpectomy alone versus oncoplastic reduction) was not associated with local recurrence or any recurrence on univariate and multivariate analyses.

CONCLUSION

Despite the oncoplastic reduction patients having a higher risk of recurrence and a more generous tumor resection, the long-term recurrence rates were equivalent when compared to breast-conserving therapy alone.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Comparison of patient-reported outcomes among different types of oncoplastic breast surgery procedures

BACKGROUND

This study aims to compare patient-reported outcomes (PROs) after different types of oncoplastic surgery (OPS) procedures and correlate the results with previously published normative data from women with no prior history of breast cancer (BC) and breast surgery.

METHODS

Cross-sectional study of patients with stage I-II BC undergoing a specific selection of OPS procedures from 04/2012 to 12/2018 by three breast surgeons at a single tertiary referral hospital in Switzerland. PROs were evaluated using the postoperative BREAST-Q questionnaire.

RESULTS

One hundred twenty-seven patients met the inclusion criteria and were surveyed. All OPS techniques achieved comparably elevated scores in satisfaction with breasts, psychosocial, and sexual well-being. Compared to normative data of healthy women, all OPS groups postoperatively achieved significantly better satisfaction with breasts, psychosocial, and sexual well-being.

CONCLUSION

This study shows high PROs across all types of OPS, which were superior to normative data from healthy women. Our findings confirm that OPS is associated with high quality of life and patient satisfaction.

Comparing costs of standard Breast-Conserving Surgery to Oncoplastic Breast-Conserving Surgery and Mastectomy with Immediate two-stage Implant-Based Breast Reconstruction

BACKGROUND

Conventional breast-conserving surgery (C-BCS) has equal oncological outcomes and superior cosmetic and patient-reported outcomes compared to mastectomy with immediate two-stage implant-based breast reconstruction (M-IBR). Oncoplastic breast-conserving surgery (OP-BCS) is increasingly being used, as it often has better cosmetic results and it enables larger tumour resection. However, OP-BCS and M-IBR compared to C-BCS lengthens operative time and might lead to more complications and consequently to additional costs. Therefore, this study aimed to compare costs and complication rates of C-BCS, OP-BCS and M-IBR.

METHODS

This single-centre, retrospective cohort study, calculated costs for all patients who had undergone breast cancer surgery between January 2014 and December 2016. Patient-, tumour- and surgery-related data of C-BCS, OP-BCS and M-IBR patients were retrieved by medical record review. Treatment costs were calculated using hospital financial data. Differences in costs and complications were analysed.

RESULTS

A total of 220 patients were included: 74 patients in the C-BCS, 78 in the OP-BCS and 68 in the M-IBR group. From most expensive to least expensive, differences in total costs were found between C-BCS vs. OP-BCS and C-BCS vs. M-IBR (p=<0.01 and p=0.04, respectively). Costs of OP-BCS and M-IBR were comparable. Complication rates were 5.5% for C-BCS, followed by 17% for OP-BCS, and 34% for M-IBR (p<0.01).

CONCLUSION

Considering total treatment costs, OP-BCS was financially non-inferior to M-IBR, whereas complication rates were higher following M-IBR. Therefore, when considering other benefits of OP-BCS, such as higher patient-reported outcomes and similar oncological outcomes, a shift from M-IBR to BCS using oncoplastic techniques seems justified.

Comparative UK Cross-sectional Study of Breast Cancer Patient-Reported Outcomes for Breast-Conserving Surgery and Immediate Reconstruction, Including Contribution to an International Collaborative Pilot Study

INTRODUCTION

Breast-conserving surgery (BCS) with adjuvant radiotherapy is oncologically comparable to mastectomy with immediate breast reconstruction (IBR) in treating breast cancer. This tertiary UK centre cross-sectional study compared BCS patient-reported outcomes with those of immediate implant-based (IBR) and free flap reconstruction (FFR), and included a contribution to a pilot international collaboration co-ordinated through the Organisation for Economic Cooperation and Development (OECD).

METHODS

Validated BREAST-Q™ 'satisfaction with breasts' modules were administered to 271 consecutive patients for six months after unilateral BCS, IBR, or FFR were conducted between June and October 2018. Risk adjustment data were collected on age, body mass index, smoking, radiotherapy, specimen weight, and tumour burden.

RESULTS

A total of 190 women returned completed questionnaires (131 BCS, 42 IBR, 17 FFR; 70% response rate). BCS scores (mean 68, standard deviation (SD) 23) were higher than those for IR overall (62, SD 23, p=0.04) and IBR (61, 24, p=0.03) but equivalent to those for FFR (66, SD 23, p=0.33). There was no significant difference in Q-Scores between the IBR and FFR groups (p=0.77). Scores were only minimally changed by risk adjustment and comparable to OECD mean international scores for IBR (61) and FFR (66).

CONCLUSIONS

This is the first study to compare BCS and IR outcomes using a validated scale. BREAST-Q™ 'satisfaction with breasts' scores were comparable between BCS and FFR but significantly lower following IBR.

Innovative Standards in Oncoplastic Breast Conserving Surgery: From Radical Mastectomy to Extreme Oncoplasty

BACKGROUND

Oncoplastic breast conserving surgery (OBCS), which is the current procedure of choice for eligible BC patients, describes a philosophy that prioritizes oncologic and cosmetic outcomes. However, knowledge gaps regarding training, acceptance, and practice preclude standardization and make it difficult to design algorithmic guidelines to optimize individualized management in the era of precision medicine.

SUMMARY

The harmony between patient expectations and oncologic goals creates the state of the art of OBCS. Nevertheless, to achieve these goals, multidisciplinary approach is a must. Surgical decisions require a comprehensive evaluation including patient factors, tumor biology, genetics, technical considerations, and adjunct therapies. Moreover, the quality-of-life (QOL) issues should be considered as the highest level of priority with a shared decision making instituted on realistic discussions with the patient.

KEY MESSAGES

The standardization in OBCS should be initiated via defining a breast surgeon who should gain theorical and practical competence on techniques via national or international educational programs. The algorithmic patient assessment with appropriate documentation before and after surgery should be established. A simple and safe global lexicon should be designed regarding techniques to be proposed and quality metrics to be considered. Additionally, international multicenter prospective trials should be instituted to overcome knowledge gaps. It is evident that OBCS is the perfect union of science with art. Nevertheless, at the very end, the question is not the nature of the surgeon/artist who would be the extremist, the innovator, or the conservative, but the patient's satisfaction, prognosis, and QOL that conclude the cascade of state of the art of OBCS.

Oncological Safety, Surgical Outcome, and Patient Satisfaction of Oncoplastic Breast-Conserving Surgery With Contralateral Balancing Reduction Mammoplasty

Introduction

Oncoplastic breast-conserving surgery (OBCS) is considered a cornerstone in the management of locally invasive breast cancer. We evaluated patient-reported outcomes of OBCS with contralateral balancing breast reduction mammoplasty and reviewed its oncologic outcomes and complications.

Methods

This is mixed method study design using retrospective chart review and prospective cohort study. Patient demographics were reviewed. Outcome measures included clinicopathologic characteristics, complications, margin status, local recurrence, tumor histopathologies, duration of follow-up, patient satisfaction, self-esteem, event-related stress, and quality of life.

Results

A total of 48 patients were included in this study. Complete excision with negative margins was obtained in 42 (87.5%) patients, positive margins in 6 (12.5%) patients, all who had re-excision with repeat lumpectomy. Thirteen patients developed minor complications, defined as being managed as an outpatient. No patients developed major complications requiring inpatient admission. These complications did not delay commencement of chemotherapy or radiotherapy. Postsurgery BREAST-Q^TM26 scores demonstrated no statistical difference in satisfaction with breasts, nipples, and sexual well-being. There was high satisfaction with overall outcome with average score of 80.8%. For the Rosenberg self-esteem scale, the results were similar for 3- and 12-month post-operative indicating maintenance of normal self-esteem post-operatively. The Impact of Events Scale showed statistically significant difference at 12-month post-operative (25.1) when compared with preoperative scores indicating that patients had lower event-related stress. There was no significant change in Hospital Anxiety and Depression Scale.

Conclusion

Our study has shown that the patient who undergo OBCS have high patient-reported outcomes with acceptable oncologic outcomes and complication rates.

Outcome reporting in therapeutic mammaplasty: a systematic review

Background

Therapeutic mammaplasty (TM) is an oncological procedure which combines tumour resection with breast reduction and mastopexy techniques. Previous systematic reviews have demonstrated the oncological safety of TM but reporting of critically important outcomes, such as quality of life, aesthetic and functional outcomes, are limited, piecemeal or inconsistent. This systematic review aimed to identify all outcomes reported in clinical studies of TM to facilitate development of a core outcome set.

Methods

Medline, EMBASE, CINAHL and Web of Science were searched from inception to 5 August 2020. Included studies reported clinical outcomes following TM for adult women. Two authors screened articles independently for eligibility. Data were extracted regarding the outcome definition and classification type (for example, oncological, quality of life, etc.), time of outcome reporting and measurement tools.

Results

Of 5709 de-duplicated records, 148 were included in the narrative synthesis. The majority of studies (n = 102, 68.9 per cent) reported measures of survival and/or recurrence; approximately three-quarters (n = 75, 73.5 per cent) had less than 5 years follow-up. Aesthetic outcome was reported in half of studies (n = 75, 50.7 per cent) using mainly subjective, non-validated measurement tools. The time point at which aesthetic assessment was conducted was highly variable, and only defined in 48 (64.0 per cent) studies and none included a preoperative baseline for comparison. Few studies reported quality of life (n = 30, 20.3 per cent), functional outcomes (n = 5, 3.4 per cent) or resource use (n = 28, 18.9 per cent).

Conclusion

Given the oncological equivalence of TM and mastectomy, treatment decisions are often driven by aesthetic and functional outcomes, which are infrequently and inconsistently reported with non-validated measurement tools.

Oncoplastic breast-conserving surgery for women with primary breast cancer

BACKGROUND

Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.

OBJECTIVES

Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.

DATA COLLECTION AND ANALYSIS

Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.

MAIN RESULTS

We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.

AUTHORS' CONCLUSIONS

The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

Psychological and Aesthetic Outcomes in Breast Cancer Patients

Background:

Patients who undergo breast cancer treatment require psychosocial and aesthetic rehabilitation. Advantages of breast reconstruction in-patient rehabilitation are well known. Oncoplastic organ-preserving surgery offers aesthetically better results, yet is often considered less safe than more radical procedures. We compared the aesthetic and psychological outcomes in patients undergoing breast reconstruction and oncoplastic breast cancer treatment.

Methods:

In total, 1130 patients who received either breast reconstruction or oncoplastic breast cancer surgery were included in the study. Patients were classified into two groups. Group 1 included 510 patients who received breast reconstruction surgery. Group 2 included 620 patients who received oncoplastic surgery. The following aspects were compared between the two groups: demographics, tumor progression, and immunohistochemical aspects, complications, hospitalization stay, and psychological and aesthetic outcomes.

Results:

Patients in the oncoplastic group showed statistically significant higher psychosocial and aesthetic outcomes, as well as lower incidence of complications, revision rate, disease progression, and recurrence. The majority of oncoplastic patients were treated in early stages of breast cancer.

Conclusion:

Offering superior treatment results, oncoplastic organ-preserving surgery should be favored in patients with earlier stages of cancer progression.

Comparative study of surgical and oncological outcomes in oncoplastic versus non oncoplastic breast-conserving surgery for breast cancer treatment

Background: Oncoplastic surgery has been increasingly used in breast cancer treatment and allows the performance of breast-conserving surgery in cases of larger tumors with unfavorable location or tumor-breast disproportion. Purpose: To compare surgical and oncological outcomes of patients undergoing oncoplastic and nononcoplastic breast-conserving surgery. Methods: Retrospective cohort study with convenience sampling of 866 patients who consecutively underwent breast-conserving surgery from 2011 to 2015. Results: The mean follow-up was 50.4 months. Nononcoplastic breast conservation surgery was performed on 768 (88.7%) patients and oncoplastic surgery on 98 (11.3%) patients. Patients in the oncoplastic group were younger (p<0.0001) and most were premenopausal (p<0.0001). Comorbidities such as diabetes (p=0.003) and hypertension (p=0.0001) were less frequent in this population. Invasive carcinoma >2 cm (p<0.0001), multifocality (p=0.004), ductal in situ carcinoma (p=0.0007), clinically positive axilla (p=0.004), and greater weight of surgical specimens (p<0.0001) were more frequent in the oncoplastic group. A second surgery for margin re-excision was more frequently performed in the nononcoplastic group (p=0.027). There was more scar dehiscence in the oncoplastic group (p<0.001), but there was no difference in early major complications (p=0.854), conversion to mastectomy (p=0.92), or local recurrence (p=0.889). Conclusion: Although used for the treatment of larger and multifocal tumors, surgical re-excisions were performed less often in the oncoplastic group, and there was no increase in conversion to mastectomy or local recurrence. In spite of the higher rate of overall complications in the oncoplastic group, major complications were similar in both groups.

Oncoplastic breast surgery versus conventional breast conserving surgery - a prospective follow-up study of subjective loco-regional late morbidity

Background and aim: Few studies have focused on the symptoms of loco-regional morbidity in shoulders, arms, and breasts related to oncoplastic breast surgery (OPS). This study aimed to determine if a difference exists in the prevalence or variety of subjective symptoms of shoulder, arm, and breast morbidity in patients undergoing OPS compared with patients receiving conventional breast conserving surgery (C-BCS). Cosmetic result and body image were included as secondary endpoints.Methods: This prospective follow-up study with 18 months of questionnaire-based follow-up included women with breast cancer or ductal carcinoma in situ. They were divided into two groups - C-BCS or OPS - depending on type of surgery performed. Furthermore, patient, disease, and treatment characteristics were recorded.Results: Among 334 completers, 229 (69%) received C-BCS and 105 (31%) received OPS. Participants were comparable regarding age, comorbidity, BMI, re-excision rate (15-16%), and axillary surgery. As for tumor characteristics, a more advanced disease stage was shown in the OPS than in the C-BCS group with larger tumor and lumpectomy size, more multifocality, and the corresponding following systemic adjuvant therapy.The questionnaire revealed that the two groups were comparable with no significant differences in frequency or variety of symptoms of shoulder and arm morbidity. Overall, participants were highly satisfied with the cosmetic results in both groups and no significant inter-group differences were observed.Conclusion: In patients with larger tumors, breast conserving surgery utilizing oncoplastic techniques yields results regarding subjective shoulder, arm, and breast morbidity as well as cosmetic outcome comparable with those of C-BCS performed on smaller tumors.Trial registration: ClinicalTrials.gov, registration number: NCT02159274 (2014).HIGHLIGHTSSubjective symptoms of shoulder, arm, and breast morbidity are comparable when oncoplastic breast surgery is compared to conventional breast conserving surgery.The variety of symptoms of shoulder and arm morbidity following oncoplastic surgery does not differ from symptoms following conventional breast conserving surgery.The cosmetic outcome following oncoplastic breast surgery is comparable to breast conserving surgery without oncoplastic techniques.

Association between Paravertebral Block and Pain Score at the Time of Hospital Discharge in Oncoplastic Breast Surgery: A Retrospective Cohort Study

BACKGROUND

Using nonopioid analgesics may decrease the risk of patients chronically using opioids postoperatively. The authors evaluated the relationship between paravertebral block and pain score at the time of hospital discharge.

METHODS

The authors performed a retrospective cohort study of 89 women with American Society of Anesthesiologists Physical Status I to III undergoing oncoplastic breast surgery with 20 to 50 percent breast tissue removal and immediate contralateral reconstruction between August of 2015 and August of 2018. The primary outcome was pain score at hospital discharge with or without paravertebral block. The secondary outcome was postoperative length of stay. Data were analyzed using the Wilcoxon rank sum test, t test, Fisher's exact test, univariable and multivariable regression, Kaplan-Meier analyses, and Cox regression.

RESULTS

Median pain score at hospital discharge was lower with paravertebral block [2 (interquartile range, 0 to 2) compared to 4 (interquartile range, 3 to 5); p < 0.001]. Multivariable regression revealed that pain score at the time of hospital discharge was inversely associated with paravertebral block after adjusting for age, body mass index, American Society of Anesthesiologists class, extent of lymph node surgery, and duration of surgery (p < 0.001). Pain score at hospital discharge was also associated with total opioid consumption during the first 24 hours after surgery (p = 0.001). Patients who received paravertebral blocks had median total 24-hour postoperative opioid consumption in morphine equivalents of 7 mg (interquartile range, 3 to 10 mg) compared with 13 mg (interquartile range, 7 to 18 mg) (p < 0.001), and median length of stay of 18 hours (interquartile range, 16 to 20 hours) compared with 22 hours (interquartile range, 21 to 27 hours) (p < 0.001).

CONCLUSION

Paravertebral blocks are associated with decreased pain score at the time of hospital discharge.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Strategies for the selection of oncoplastic techniques in the treatment of early-stage breast cancer patients

BACKGROUND

In recent years, breast cancer is the most common malignancy in women. The traditional method of surgery is to remove a woman's breast completely, which has a negative impact on her work and life. Today, women have a fiery pursuit to maintain their perfect figure, which has forced breast surgeon to find a new surgical approach to maintain the shape of the breast after surgery.

METHODS

This study systematically analyzed and summarized the incision design and repair of glandular defects in early-stage breast cancer patients by oncoplastic breast techniques. By summarizing the methods of oncoplastic breast surgery (OBS) in different quadrants, it could help beginners to master this technology more quickly, so as to provide better help for breast cancer patients.

RESULTS

A total of 216 breast cancer patients who underwent OBS from January 2016 to June 2020 at the Affiliated Hospital of Guangdong Medical University were included in this study. In patients treated with the volume-displacement method and the volume-replacement method, 92.6% and 86.2% of patients achieved excellent breast shape, respectively.

CONCLUSIONS

OBS is a safe and effective way to treat early-stage breast cancer while obtaining better breast shape, reducing postoperative psychological trauma, and improving quality of life.

Improving Results in Oncoplastic Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the risks, benefits, and safety profile of oncoplastic procedures for partial breast reconstruction, and how they compare to breast conservation-therapy alone. 2. Have a working knowledge of oncoplastic techniques and how they are addressed from the multidisciplinary perspective. 3. Understand the limitations of oncoplastic techniques and how to avoid unfavorable results.

SUMMARY

Oncoplastic surgical techniques have expanded indications for breast conservation and have improved both oncologic and reconstructive outcomes. This article will focus on some of the barriers to adoption and discuss ways to improve safety through streamlining the process, understanding the oncologic concerns, and evaluating unfavorable outcomes that might interfere with the appropriate delivery of breast cancer care.

Protocol for a mixed-method study to inform the feasibility of undertaking a large-scale multicentre study comparing the clinical and patient-reported outcomes of oncoplastic breast conservation as an alternative to mastectomy with or without immediate breast reconstruction in women unsuitable for standard breast-conserving surgery (the ANTHEM Feasibility Study)

INTRODUCTION

Approximately 40% of the 55 000 women diagnosed with breast cancer each year in the UK undergo mastectomy because they are considered unsuitable for standard breast-conserving surgery (BCS) due to tumour size or multiple tumour foci. Mastectomy can significantly impact women's quality of life, and only one in four women currently undergo immediate breast reconstruction (IBR).Level 2 oncoplastic breast-conserving surgery (OPBCS) combines removing the cancer with a range of plastic surgical volume replacement (eg, local perforator flaps) and volume displacement techniques (eg, therapeutic mammaplasty) that can extend the role of BCS and may allow some women not suitable for standard BCS to avoid mastectomy. High-quality research to determine whether OPBCS offers a safe and effective alternative to mastectomy±IBR is currently lacking. Preliminary work is needed to ensure a future large-scale study is feasible and well designed and addresses questions important to patients and the National Health Service.

METHODS AND ANALYSIS

Mixed methods will be used to inform feasibility and design of a future large-scale study comparing the clinical effectiveness and cost-effectiveness of OPBCS and mastectomy±IBR. It will have four parts: (1) a National Practice Questionnaire to determine current practice and provision of oncoplastic breast and reconstructive surgery in the UK; (2) a pilot multicentre prospective cohort study to explore the proportion of patients choosing OPBCS versus mastectomy, the proportion in OPBCS is successful and clinical and patient-reported outcomes of different techniques at 3 and 12 months postsurgery; (3) a qualitative interview study to explore patients' attitudes to different procedures, rationale for decision-making and perceptions of outcomes; and (4) design of the future study.All centres offering OPBCS and mastectomy in the UK will be invited to participate. Recruitment is planned to commence winter 2020 and continue for 12 months.

ETHICS AND DISSEMINATION

The study has ethical approval from the Wales Research Ethics Committee 6 National Research Ethics Service (REC Ref 20/WA/0225). Results will be presented at national and international meetings and published in peer-reviewed journals. We will work with patients to develop lay summaries and share these through patient groups and breast cancer charities.

TRIAL REGISTRATION NUMBER

ISRCTN18238549.

A comprehensive literature review of patient-reported outcome measures (PROMs) among common breast reconstruction options: What types of breast reconstruction score well?

PURPOSE

Breast cancer continues to be the most prevalent cancer affecting women. Many reconstructive options exist after oncologic resection. Breast reconstruction can have a lasting impact on many areas of the patient's life, and therefore, a high consideration for patient satisfaction is crucial. Patient-reported outcome measures (PROMs) provide an important tool in the evaluation of different surgical methodologies. The aim of this comprehensive systematic review is to look at various surgical modalities in breast reconstruction as they relate to patient satisfaction.

METHODS

A PubMed PRISMA search was performed. Criteria for inclusion included nipple-sparing or skin-sparing mastectomy with autologous or implant-based reconstruction, level 2 volume displacement or volume replacement oncoplastic surgery, and measurement of patient-reported outcomes using the BREAST-Q or other validated PROMs. From the data set, weighted proportions were generated and analyzed using the Kruskal-Wallis rank sum test and a post hoc Dunn's test.

RESULTS

After obtaining 254 full text copies, 43 articles met inclusion criteria and were included. Analysis of BREAST-Q data showed oncoplastic breast surgery was significantly preferred over mastectomy regardless of the type of reconstruction. Nipple-sparing was significantly preferred over skin-sparing mastectomy, autologous reconstruction was significantly preferred over implant-based reconstruction, and prepectoral implant placement was preferred over subpectoral implant placement. Validated PROMs other than BREAST-Q showed similar trends in all but type of mastectomy.

CONCLUSIONS

In this comprehensive systematic review, oncoplastic surgery showed the most favorable PROMs when compared to other reconstructive modalities. Autologous was preferred over implant-based reconstruction, and prepectoral was preferred over subpectoral implant placement.

The Landmark Series: Breast Conservation Trials (including oncoplastic breast surgery)

Significant progress has been made in the treatment and outcome of breast cancer. Some of the most dramatic strides have been in the surgical management of breast cancer. Breast-conserving therapy (BCT), including wide local excision of the tumor followed by irradiation, has become a standard treatment option for women with early-stage invasive breast cancer. Large cooperative group trials have contributed to the paradigm shift from mastectomy to BCT. This review reports the landmark BCT trials that provided the data for current surgical practices. The review also describes the body of literature contributing to the increasing use of oncoplastic techniques for patients undergoing BCT.

Oncoplastic partial breast reconstruction: concepts and techniques

Immediate oncoplastic breast reconstruction performed at the time of breast conserving surgery for the treatment of breast cancer merges the therapeutic goals of complete oncologic extirpation with preservation of breast form and function. A constellation of surgical techniques that employs breast volume displacement and/or replacement methods of varying complexity levels have emerged, thus broadening the potential applications for breast conservation therapy to include cases with increased tumor-to-native breast-volume ratios, multicentric or multifocal disease, and/or previous margin-positive resections. This review describes the various reconstructive methods, including the use of local tissue rearrangement, oncoplastic reduction-mastopexy, and locoregional flaps. Classification of the surgical options into levels I and II volume-displacement and volume-replacing techniques is made. Additionally, we explore the oncologic safety and effectiveness of this treatment paradigm by summarizing existing supportive evidence regarding associated risk of surgical complications, rate of margin-positive resection, implications for radiographic surveillance, local recurrence rates, and patient-reported outcomes. In conclusion, surgeons may use a wide variety of oncoplastic techniques for partial breast reconstruction at the time of segmental mastectomy to deliver effective breast conserving treatment for women with breast cancer. A growing body of literature affirms the oncologic safety of this approach. Future directions for research include long-term follow-up data with emphasis on outcomes from patient perspectives.

Comparison of Oncoplastic Breast-Conserving Therapy and Standard Breast-Conserving Therapy in Early-Stage Breast Cancer Patients

Background

The aim of this study was to compare the efficacy and safety of oncoplastic breast-conserving therapy (OBCT) and SBCT (standard breast-conserving therapy) in breast cancer surgery.

Material/Methods

We enrolled 192 breast cancer patients who underwent breast-conserving surgery during January 2015 to April 2018. The surgery strategies of OBCT and SBCT were performed according to the patients’ condition. For measurement of surgical cosmetic effects, the Harris scale, the modified objective scores, and the subjective evaluation were all used. The basic clinical characteristics, intraoperative indices, postoperative complications, metastasis, and recurrence during the 2-year follow-up were recorded.

Results

The mean surgical time was remarkably longer and the resected volume was markedly larger in the OBCT group than in the SBCT group. The excellent and good ratios of Harris scale, the modified objective scores, and the ratio of very satisfied and satisfied patients by subjective scale were all significantly higher in the OBCT group than in the SBCT group. The occurrence rates of seroma and poor incision healing were remarkably lower in the OBCT group. No significant difference was found for metastasis and recurrence.

Conclusions

OBCT had better cosmetic effects, fewer complications, and no adverse effects on metastasis and recurrence.

How to Optimize Aesthetics for the Partial Mastectomy Patient

Aesthetic concern is one of the main driving forces behind the popularity of the oncoplastic approach to breast conservation therapy. Oncoplastic options at the time of lumpectomy include volume replacement techniques such as flaps and volume displacement techniques such as the oncoplastic reduction. These techniques can be employed to ensure preservation of breast shape and contour, size and symmetry, inframammary fold position, and position of the nipple-areola complex. The importance of aesthetic outcomes is not only to improve overall patient satisfaction but also to minimize the need for revisional surgeries for shape and symmetry. The purpose of this review is to discuss ways to optimize the aesthetic result and to review the evidence behind aesthetic outcomes.

A Cost-Utility Analysis Comparing Immediate Oncoplastic Surgery with Delayed Oncoplastic Surgery in Smoking Breast Cancer Patients

BACKGROUND

Oncoplastic reduction mammoplasty for smoking breast cancer patients committed to smoking cessation may be performed immediately (increasing smoking-related risk) or in a delayed fashion (increasing radiation-related risk).

OBJECTIVE

Our aim was to examine the cost utility of immediate versus delayed oncoplastic reconstruction when operating on a smoking patient with breast cancer and macromastia with a long-term commitment to smoking cessation.

METHODS

A literature review determined the probabilities and outcomes for the treatment of unilateral breast cancer with immediate or delayed oncoplastic surgery. Reported utility scores were used to estimate quality-adjusted life-years (QALYs) for varying health states. A decision analysis tree was constructed with rollback analysis to highlight the more cost-effective strategy, and an incremental cost-utility ratio (ICUR) was calculated. Sensitivity analyses were performed to validate the robustness of the results.

RESULTS

Immediate oncoplastic surgery is associated with a higher clinical effectiveness (QALY) of 33.3 compared with delayed oncoplastic surgery (33.26), with a higher increment of clinical effectiveness of 0.07 and relative cost reduction of $3458.11. This resulted in a negative ICUR of -50,194, which favored immediate reconstruction, indicating a dominant strategy. In one-way sensitivity analyses, delayed reconstruction was the more cost-effective strategy if the probability of successful immediate reconstruction falls below 29% or its cost exceeds $29,611. Monte-Carlo analysis showed a confidence of 99% that immediate oncoplastic surgery is more cost effective.

CONCLUSIONS

Despite the risk of postoperative complications associated with smoking, immediate oncoplastic surgery is more cost effective compared with delayed oncoplastic surgery in which reconstructive surgery would occur after radiation.

The Role of Oncoplastic Surgery for Breast Cancer

OPINION STATEMENT

Oncoplastic surgery (OPS) expands the indications and possibilities of breast-conserving surgery (BCS) by allowing for a wider cancer resection than lumpectomy. Ongoing investigation and reporting of OPS outcomes along with improvements in comprehensive training in breast surgical oncology will impact on awareness and lead to increased adoption of these techniques. Indications for OPS include concern about clear margins, poor tumor location (upper inner pole and lower quadrant), multifocality, need for skin excision, and poor candidacy for mastectomy and reconstruction. OPS has been proven to be oncological safe with comparable rates of complications, positive margins, and re-excisions with BCS. Additionally, OPS has a positive impact on the quality of life and self-esteem when compared with those patients that underwent BCT.

The Effect of Surgical Treatment on the Quality of Life of Young Women with Breast Asymmetry: A Longitudinal, Cohort Study

BACKGROUND

Young women with congenital breast asymmetry have impaired psychological well-being and self-esteem. However, little is known regarding the effects of surgical intervention in this population. This cohort study aims to assess postoperative changes in health-related quality of life following surgical treatment of breast asymmetry in young women using a prospective, longitudinal study design.

METHODS

From 2008 to 2018, 45 young women undergoing surgical correction of breast asymmetry of benign cause and 101 unaffected, female controls completed the following surveys: Short-Form 36v2, Rosenberg Self-Esteem Scale, and Eating-Attitudes Test-26. Surveys were administered at baseline and at up to 9-year follow-up.

RESULTS

Participants with breast asymmetry scored significantly worse than controls at baseline on the Rosenberg Self-Esteem Scale and in two Short-Form 36v2 domains: Social-Functioning and Role-Emotional. Asymmetry participants experienced significant postoperative improvements on the Rosenberg Self-Esteem Scale, and in three Short-Form 36v2 domains: Role-Physical, Social Functioning, and Mental Health. These improvements were sustained for a minimum of 5 years. Postoperatively, asymmetry participants' quality of life was comparable to controls and did not vary by age at the time of surgery, asymmetry severity, or diagnosis.

CONCLUSIONS

Surgical treatment of breast asymmetry in young women yields significant and sustained improvements in psychosocial quality of life. Postoperatively, patients returned to a level of functioning commensurate with their peers.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Rates of re-excision and conversion to mastectomy after breast-conserving surgery with or without oncoplastic surgery: a nationwide population-based study

Background

There is no consensus regarding the impact of oncoplastic surgery (OPS) on rates of re‐excision and conversion to mastectomy following breast‐conserving surgery (BCS). Here these two outcomes after BCS and OPS were compared in a nationwide population‐based setting.

Methods

In Denmark, all OPS is registered and categorized into volume displacement, volume reduction or volume replacement. Patients who underwent BCS or OPS between 2012 and 2018 were selected from the Danish Breast Cancer Group database. Multivariable analyses were performed to adjust for confounders, and propensity score matching to limit potential confounding by indication bias.

Results

A total of 13 185 patients (72·5 per cent) underwent BCS and 5003 (27·5 per cent) OPS. Volume displacement was used in 4171 patients (83·4 per cent), volume reduction in 679 (13·6 per cent) and volume replacement in 153 (3·1 per cent). Re‐excision rates were 15·6 and 14·1 per cent after BCS and OPS respectively. After adjusting for confounders, patients were less likely to have a re‐excision following OPS than BCS (odds ratio (OR) 0·80, 95 per cent c.i. 0·72 to 0·88), specifically after volume displacement and reduction. The rate of conversion to mastectomy was similar after OPS and BCS (3·2 versus 3·7 per cent; P = 0·105), but with a lower risk in adjusted analysis (OR 0·69, 0·58 to 0·84), specifically after volume displacement and reduction procedures. Findings were similar after propensity score matching.

Conclusion

A modest decrease in re‐excision rate and less frequent conversion to mastectomy were observed after OPS compared with BCS.

Analysis of Utility Assessment Scores to Objectify the Health Burden Caused by Breast Conservation Therapy

Background

Lumpectomy followed by radiation, known as breast conservation therapy (BCT), is a viable surgical treatment option for early-stage breast cancer. However, the current literature suggests that patients prefer mastectomy over BCT, likely due to the wide variety of postmastectomy reconstructive options. Our aim is to investigate the objective health burden of living with BCT to help surgeons gain a better understanding of patient treatment preferences.

Methods

Three validated health state utility tools were used to objectify the burden of living with post-BCT results: visual analogue scale (VAS), time trade-off (TTO), and standard gamble (SG). A prospective sample of the general population and medical students were recruited, and their responses analyzed to attain these scores.

Results

Utility scores for living with BCT are VAS 0.81 ± 0.19, TTO 0.93 ± 0.10, and SG 0.92 ± 0.14. The TTO and SG suggest a willingness to trade 2.5 years of life years and an 8% chance of death undergoing reconstructive procedures to correct a BCT defect, respectively. Age, gender, race, education, and income were not statistically significant independent predictors for higher or lower utility scores.

Conclusion

The impact of the health burden of BCT was ascertained using validated objective numeric utility scores. These indices demonstrate a willingness to trade less life years to undergo correction of a BCT defect than reconstruction following unilateral mastectomy. They can provide surgeons with the best objective understanding of patient preferences for shared decision-making in the management of breast cancer.

Quality-of-Life and Surgical Outcomes for Breast Cancer Patients Treated with Therapeutic Reduction Mammoplasty Versus Mastectomy with Immediate Reconstruction

BACKGROUND

Therapeutic reduction mammoplasty (TRM) is a safe and effective surgical technique that has oncologic outcomes comparable with those achieved by mastectomy. This study aimed to compare surgical and patient-reported outcomes between breast cancer patients treated with TRM and those who had mastectomy with immediate reconstruction (MIR).

METHODS

A 4-year, single-institution, retrospective cohort study analyzed breast cancer patients undergoing TRM and MIR. Patient characteristics and perioperative data were collected from electronic records. Patient-reported outcome data were collected via BREAST-Q questionnaires preoperatively, then 3 months and 12 months postoperatively. A subgroup analysis was performed on locally advanced breast cancer (LABC) patients for TRM and MIR.

RESULTS

The study included 249 breast reconstructions, of which 77 (31%) were TRM and 172 (69%) were MIR. The mean follow-up time was 2.4 ± 1.2 years. Compared with MIR, TRM had significantly lower major complication rates (9% vs 21%; p = 0.02) and fewer revisionary surgeries (5% vs 37%; p < 0.0001). At 1 year postoperatively, TRM had a significantly greater change in satisfaction with breasts, (+ 27.7 vs + 4.6; p < 0.01) and sexual well-being (+ 20.0 vs - 5.5; p = 0.02) than MIR.

CONCLUSION

For select breast cancer patients, TRM continues to be a safe and effective alternative to mastectomy. The current study demonstrated that TRM patients had fewer major complications and revisionary surgeries, as well as better patient-reported outcomes than MIR.

Does oncoplastic surgery increase immediate (30-day) postoperative complications? An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database

PURPOSE

Although there has been a significant increase in the use of oncoplastic surgery (OPS), data on the postoperative safety of this approach are limited compared to traditional lumpectomy. This study aimed to compare the immediate (30-day) postoperative complications associated with OPS and traditional lumpectomy.

METHODS

An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was performed on women with breast cancer who underwent OPS or traditional lumpectomy. Logistic regression was used to explore the effect of type of surgery on the outcome of interest.

RESULTS

A total of 109,487 women were analyzed of whom 8.3% underwent OPS. OPS had a longer median operative time than traditional lumpectomy. The unadjusted immediate (30-day) overall complication rate was significantly higher with OPS than traditional lumpectomy (3.8% versus 2.6%, p < 0.001). After adjusting for baseline differences, overall 30-day postoperative complications were significantly higher amongst women undergoing OPS compared with traditional lumpectomy (OR 1.41, 95%CI 1.24-1.59). Factors that were independent predictors of overall 30-day complications included higher age, higher BMI, race, smoking status, lymph node surgery, neoadjuvant chemotherapy, ASA class ≥ 3, in situ disease, and year of operation. The interaction term between type of surgery and operative time was not statistically significant, indicating that operative time did not modify the effect of type of surgery on immediate postoperative complications.

CONCLUSIONS

Although there were slightly higher overall complication rates with OPS, the absolute rates remained quite low for both groups. Therefore, OPS may be performed in women with breast cancer who are suitable candidates.

Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP Database: Are We Following National Guidelines?

BACKGROUND

For patients with ductal carcinoma in situ (DCIS), multiple national cancer organizations recommend that sentinel lymph node biopsy (SLNB) be offered when treated with mastectomy, but not when treated with breast-conserving surgery (BCS). This study analyzes national surgical trends of SLNB and axillary lymph node dissection (ALND) in DCIS patients undergoing breast surgery with the aim to quantify deviations from national guidelines.

METHODS

A retrospective cohort analysis of the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2017 identified patients with DCIS. Patients were categorized by their primary method of breast surgery, i.e. mastectomy or BCS, then further categorized by their axillary lymph node (ALN) management, i.e. no intervention, SLNB, or ALND. Data analysis was conducted via linear regression and a non-parametric Mann-Kendall test to assess a temporal trend and Sen's slope.

RESULTS

Overall, 43,448 patients with DCIS met the inclusion criteria: 20,504 underwent mastectomy and 22,944 underwent BCS. Analysis of DCIS patients from 2005 to 2017 revealed that ALND decreased and SLNB increased in every subgroup, regardless of surgical treatment modality. Evaluation in the mastectomy group increased overall: mastectomy alone increased from 57.1 to 65.8% (p < 0.01) and mastectomy with immediate reconstruction increased from 58.5 to 72.1% (p < 0.01). Increases also occurred in the total BCS population: partial mastectomy increased from 14.0 to 21.1% and oncoplastic surgery increased from 10.5 to 23.0% (both p < 0.01).

CONCLUSIONS

Despite national guideline recommendations for the management of ALN surgery in DCIS patients, approximately 20-30% of cases continue to not follow these guidelines. This warrants further education for surgeons and patients.

Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction

BACKGROUND

Therapeutic mammaplasty (TM) may be an alternative to mastectomy, but few well designed studies have evaluated the success of this approach or compared the short-term outcomes of TM with mastectomy with or without immediate breast reconstruction (IBR). Data from the national iBRA-2 and TeaM studies were combined to compare the safety and short-term outcomes of TM and mastectomy with or without IBR.

METHODS

The subgroup of patients in the TeaM study who underwent TM to avoid mastectomy were identified, and data on demographics, complications, oncology and adjuvant treatment were compared with those of patients undergoing mastectomy with or without IBR in the iBRA-2 study. The primary outcome was the percentage of successful breast-conserving procedures in the TM group. Secondary outcomes included postoperative complications and time to adjuvant therapy.

RESULTS

A total of 2916 patients (TM 376; mastectomy 1532; mastectomy and IBR 1008) were included in the analysis. Patients undergoing TM were more likely to be obese and to have undergone bilateral surgery than those having IBR. However, patients undergoing mastectomy with or without IBR were more likely to experience complications than the TM group (TM: 79, 21·0 per cent; mastectomy: 570, 37·2 per cent; mastectomy and IBR: 359, 35·6 per cent; P < 0·001). Breast conservation was possible in 87·0 per cent of patients who had TM, and TM did not delay adjuvant treatment.

CONCLUSION

TM may allow high-risk patients who would not be candidates for IBR to avoid mastectomy safely. Further work is needed to explore the comparative patient-reported and cosmetic outcomes of the different approaches, and to establish long-term oncological safety.

PROMs in post-mastectomy care: Patient self-reports (BREAST-Q™) as a powerful instrument to personalize medical services

One of the goals of immediate breast reconstruction (IBR) is to satisfy the patient's outcome. Recent studies therefore tended to focus on the patient's perception of the care and on the impact on quality of life using patients-reported-outcome-measures (PROMs), able to measure the health status directly without the clinician's interposition. We present a preliminary prospective study on 333 patients who underwent mastectomy with IBR in a two-year period, in a single Italian centre, using a dedicated PROMs, the BREAST-Q™, to determine the patient's satisfaction. We studied two groups of IBR: Group A (two-step with tissue-expander) and Group B (one-step: prosthesis/mesh) and conducted a pre- and post-operative comparison for each group to evaluate score-gain over time, and a group-score comparison to determine whether differences were significant between reconstruction types. Two-hundred-and-nine were actually enrolled and 132 completed all the questionnaires. The response rate was 62.8% and the compliance rate (completion of all the questionnaires) was 63.1%. In both groups all the analyzed domains worsened comparing the pre and post-operative period; the differences were statistically significant only for physical and sexual-wellbeing. In the comparison between the two groups, none of the detected differences reached the statistical significance. According to our experience, we can state that PROMs could improve the health concept redefining the variables to be monitored even if data is still insufficient to draw any definitive conclusion. PROMs can help surgeons and patients decide the most appropriate surgery for a particular patient-profile and to identify those who require further support.

Multicentre prospective observational study evaluating recommendations for mastectomy by multidisciplinary teams

BACKGROUND

Recommendations for mastectomy by multidisciplinary teams (MDTs) may contribute to variation in mastectomy rates. The primary aim of this multicentre prospective observational study was to describe current practice in MDT decision-making for recommending mastectomy. A secondary aim was to determine factors contributing to variation in mastectomy rates.

METHODS

Consecutive patients undergoing mastectomy between 1 June 2015 and 29 February 2016 at participating units across the UK were recruited. Details of neoadjuvant systemic treatment (NST), operative and oncological data, and rationale for recommending mastectomy by MDTs were collected.

RESULTS

Overall, 1776 women with breast cancer underwent 1823 mastectomies at 68 units. Mastectomy was advised by MDTs for 1402 (76·9 per cent) of these lesions. The most common reasons for advising mastectomy were large tumour to breast size ratio (530 women, 29·1 per cent) and multicentric disease (372, 20·4 per cent). In total, 202 postmenopausal women with oestrogen receptor-positive (ER+) unifocal tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 173 women (85·6 per cent). Seventy-five women aged less than 70 years with human epidermal growth factor receptor 2-positive (HER2+) tumours were advised mastectomy and not offered NST, owing to large tumour to breast size ratio in 45 women (60 per cent).

CONCLUSION

Most mastectomies are advised for large tumour to breast size ratio, but there is an inconsistency in the use of NST to downsize tumours in patients with large ER+ or HER2+ cancers. The application of standardized recommendations for NST could reduce the number of mastectomies advised by MDTs.