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Ali OAH, Elhaj A. How Can Oncoplastic Breast Surgery Contribute to the Management of Locally Advanced Breast Cancer in Sub-Saharan Africa? Breast Care (Basel) 2023; 18:336-343. [PMID: 37901048 PMCID: PMC10601675 DOI: 10.1159/000531151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/17/2023] [Indexed: 10/31/2023] Open
Abstract
Background Because of resource constrains in sub-Saharan African countries, breast-conserving surgery (BCS) has no role in patients with locally advanced breast cancer (LABC) following neoadjuvant chemotherapy (NACT), and mastectomy remains the standard surgical treatment for these patients. Objectives The first objective of the study was to assess the safety of oncoplastic BCS in patients with LABC who showed good clinical response to NACT in a breast center with enhanced level of resources in Sudan. The second objective was to assess the cosmetic outcome. Patients and Methods Two hundred and fifty patients with LABC were treated with NACT at Khartoum Breast Care Center during the period 2013-2019. Out of this, 52 patients were surgically treated with oncoplastic breast-conserving surgery. Kaplan-Meier curve was used to calculate the survival rates. The cosmetic outcome was subjectively assessed by the Harris scale. Results The median follow-up period was 53 months. The 3- and 5-years distant metastasis-free survival rates were 92.9% and 82.2%, respectively. One patient developed regional recurrence, and 6 patients developed distant metastasis. Eighty percentage of patients were admitted to have good to excellent cosmetic outcome. Conclusion This Sudanese experience showed that oncoplastic BCS is oncologically safe and aesthetically satisfactory in patients with LABC who demonstrated good clinical response to NACT in a setting with enhanced levels of resources for breast cancer care.
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Affiliation(s)
| | - Ahmed Elhaj
- Department of Medical Oncology, Khartoum Breast Care Centre, Khartoum, Sudan
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Level II Oncoplastic Surgery as an Alternative Option to Mastectomy with Immediate Breast Reconstruction in the Neoadjuvant Setting: A Multidisciplinary Single Center Experience. Cancers (Basel) 2022; 14:cancers14051275. [PMID: 35267583 PMCID: PMC8909600 DOI: 10.3390/cancers14051275] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 02/19/2022] [Accepted: 02/25/2022] [Indexed: 02/05/2023] Open
Abstract
Oncoplastic surgery level II techniques (OPSII) are used in patients with operable breast cancer. There is no evidence regarding their safety and efficacy after neoadjuvant chemotherapy (NAC). The aim of this study was to compare the oncological and aesthetic outcomes of this technique compared with those observed in mastectomy with immediate breast reconstruction (MIBR), in post-NAC patients undergoing surgery between January 2016 and March 2021. Local disease-free survival (L-DFS), regional disease-free survival (R-DFS), distant disease-free survival (D-DFS), and overall survival (OS) were compared; the aesthetic results and quality of life (QoL) were evaluated using BREAST-Q. A total of 297 patients were included, 87 of whom underwent OPSII and 210 of whom underwent MIBR. After a median follow-up of 39.5 months, local recurrence had occurred in 3 patients in the OPSII group (3.4%), and in 13 patients in the MIBR group (6.1%) (p = 0.408). The three-year L-DFS rates were 95.1% for OPSII and 96.2% for MIBR (p = 0.286). The three-year R-DFS rates were 100% and 96.4%, respectively (p = 0.559). The three-year D-DFS rate were 90.7% and 89.7% (p = 0.849). The three-year OS rates were 95.7% and 95% (p = 0.394). BREAST-Q highlighted significant advantages in physical well-being for OPSII. No difference was shown for satisfaction with breasts (p = 0.656) or psychosocial well-being (p = 0.444). OPSII is safe and effective after NAC. It allows oncological and aesthetic outcomes with a high QoL, and is a safe alternative for locally advanced tumors which are partial responders to NAC.
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Nanda A, Hu J, Hodgkinson S, Ali S, Rainsbury R, Roy PG. Oncoplastic breast-conserving surgery for women with primary breast cancer. Cochrane Database Syst Rev 2021; 10:CD013658. [PMID: 34713449 PMCID: PMC8554646 DOI: 10.1002/14651858.cd013658.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- Akriti Nanda
- Department of Breast Surgery, Oxford University Hospitals, Oxford, UK
| | - Jesse Hu
- Division of Breast Surgery, National University Health System, Singapore, Singapore
| | - Sarah Hodgkinson
- Editorial & Methods Department, Cochrane Central Executive, London, UK
| | - Sanah Ali
- Medical School, Oxford University, Oxford, UK
| | | | - Pankaj G Roy
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Gulcelik MA, Dogan L. Feasibility of level II oncoplastic techniques in the surgical management of locally advanced breast cancer after neoadjuvant treatment. Int J Clin Pract 2021; 75:e13987. [PMID: 33406297 DOI: 10.1111/ijcp.13987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/03/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The study aimed to identify the short- and long-term oncological results and complications of level-II oncoplastic surgery (OPS) techniques applied after neoadjuvant chemotherapy (NAC) for locally advanced breast cancer. METHODS Patients undergoing OPS because of breast cancer (non-NAC) and those undergoing OPS after systemic treatment (NAC) were evaluated. Surgical margin (SM) status, reoperation and re-excision requirements, axillary intervention results, ipsilateral tumour recurrence, axillary recurrence rates and early postoperative complications were recorded. Long-term locoregional recurrence-free survival (LRFS) and overall survival (OS) rates of the patients were analysed. RESULTS There were 1043 patients (893 patients in the non-NAC group and 150 in the NAC group) in the study. There were no significant differences in SM status, re-excision and mastectomy rates between the groups. The 5-year (LRFS) rate was 90.1% in the NAC group and 93.2% in the non-NAC group (P: .09). OS was shorter in the NAC group. Five-year OS rate was 96% in the non-NAC group and 92% in the NAC group (P: .01). There was no significant difference between the groups in terms of delayed wound healing, minor wound infection, fat necrosis, seroma/hematoma, partial nipple necrosisor T-junction necrosis. CONCLUSION It should be noted that the responses to NAC increased with targeted therapies, and breast-conserving became possible in a substantial number of patients who were not eligible for breast-conserving surgery at the first presentation. Notably, oncoplastic surgery increased breast conservation rates without compromising oncological results.
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Affiliation(s)
- Mehmet Ali Gulcelik
- Department of Surgical Oncology, University of Health Sciences Turkey, Gulhane Training and Research Hospital, Ankara, Turkey
| | - Lutfi Dogan
- Department of Surgical Oncology, University of Health Sciences Turkey, Ankara AY Oncology Training and Research Hospital, Ankara, Turkey
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Abstract
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.
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Nanda A, Hu J, Hodgkinson S, Rainsbury R, Roy PG. Oncoplastic breast-conserving surgery for women with primary breast cancer. Hippokratia 2020. [DOI: 10.1002/14651858.cd013658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akriti Nanda
- Department of Breast Surgery; Oxford University Hospitals; Oxford UK
| | - Jesse Hu
- General Surgery; Ng Teng Fong General Hospital National University Health System; Singapore Singapore
| | - Sarah Hodgkinson
- Editorial & Methods Department; Cochrane Central Executive; London UK
| | | | - Pankaj G Roy
- Department of Breast Surgery; Oxford University Hospitals; Oxford UK
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Agrawal A. Oncoplastic breast surgery and radiotherapy-Adverse aesthetic outcomes, proposed classification of aesthetic components, and causality attribution. Breast J 2019; 25:207-218. [DOI: 10.1111/tbj.13193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 01/18/2018] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Amit Agrawal
- Cambridge Breast Unit, Cambridge University Hospitals; Cambridge UK
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Hu J, Rainsbury RM, Segaran A, Predescu O, Roy PG. Objective assessment of clinical, oncological and cosmetic outcomes following volume replacement in patients undergoing oncoplastic breast-conserving surgery: protocol for a systematic review. BMJ Open 2018; 8:e020859. [PMID: 30030314 PMCID: PMC6059305 DOI: 10.1136/bmjopen-2017-020859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Oncoplastic breast surgery allows the excision of larger tumours without compromising cosmetic outcome and can be broadly divided into volume displacement and volume replacement techniques. Although oncoplastic surgery has rapidly gained acceptance and is now widely practised, evidence is still lacking especially in patients who underwent volume replacement techniques. As it is a relatively new technique that has been described in the literature in the recent years, a summary of evidence from this literature can help clinicians to understand the clinical, oncologicalandcosmetic outcomes of such procedures. METHODS AND ANALYSIS All original studies including randomised controlled trials, cohort studies, case-control studies and case series involving more than 10 women undergoing partial breast reconstruction using a volume replacement technique will be included. The primary objective is to evaluate the clinical, oncological and cosmetic outcomes following volume replacement in patients undergoing oncoplastic breast-conserving surgery. The secondary objective is to review the patient-reported outcomes (PROMs) associated with oncoplastic breast surgery to help identify any unmet needs and to consider refining the existing PROMs to suit women undergoing volume replacement surgery.A comprehensive literature search, eligibility assessment and extraction of data will be conducted by two trained teams acting independently. Data will be extracted and stored in a database with standardised extraction fields to facilitate easy and consistent data entry. Heterogeneity will be assessed using the Cochrane tests. ETHICS AND DISSEMINATION This systematic review requires no ethical approval. It will be published in a peer-reviewed journal, and it will also be presented at nationalandinternational conferences. PROSPERO REGISTRATION NUMBER CRD42017075700; Pre-results.
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Affiliation(s)
- Jesse Hu
- Department of Breast Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard M Rainsbury
- Department of Breast Surgery, Hampshire Hospitals NHS Foundation Trust, Winchester, UK
| | - Ashvina Segaran
- Department of Breast Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Oana Predescu
- Department of Breast Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Pankaj G Roy
- Department of Breast Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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Crown A, Handy N, Rocha FG, Grumley JW. Oncoplastic reduction mammaplasty, an effective and safe method of breast conservation. Am J Surg 2018; 215:910-915. [DOI: 10.1016/j.amjsurg.2018.02.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 02/23/2018] [Accepted: 02/26/2018] [Indexed: 11/28/2022]
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10
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The Expanded Use of Autoaugmentation Techniques in Oncoplastic Breast Surgery. Plast Reconstr Surg 2018; 141:10-19. [DOI: 10.1097/prs.0000000000004009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
The oncoplastic approach to breast conservation therapy has become a useful and popular option for women with breast cancer who wish to preserve their breast. The initial driving forces were aimed at minimizing the potential for a breast conservation therapy deformity; however, various other benefits have been identified that include broadening the indications for breast conservation therapy in some patients and improved margin control. The various techniques can be categorized into glandular rearrangement techniques such as breast reductions usually in patients with larger breasts or flap reconstruction such as the latissimus dorsi muscle usually in patients with smaller breasts. As the acceptance continues to increase, we are starting to see more outcomes evidence in terms of patient satisfaction, quality of life, complications, and recurrence, to further support the safety and efficacy of the oncoplastic approach.
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Neoadjuvant Therapy Combined With Oncoplastic Reduction for High-Stage Breast Cancer Patients. Ann Plast Surg 2017; 78:S258-S262. [DOI: 10.1097/sap.0000000000001062] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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De La Cruz L, Blankenship SA, Chatterjee A, Geha R, Nocera N, Czerniecki BJ, Tchou J, Fisher CS. Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Ann Surg Oncol 2016; 23:3247-58. [DOI: 10.1245/s10434-016-5313-1] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
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Piper M, Peled AW, Sbitany H, Foster RD, Esserman LJ, Price ER. Comparison of Mammographic Findings Following Oncoplastic Mammoplasty and Lumpectomy Without Reconstruction. Ann Surg Oncol 2015; 23:65-71. [DOI: 10.1245/s10434-015-4611-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 11/18/2022]
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Barranger E, Antomarchi J, Chamorey E, Cavrot C, Flipo B, Follana P, Peyrottes I, Chapellier C, Ferrero JM, Ihrai T. Effect of Neoadjuvant Chemotherapy on the Surgical Treatment of Patients With Locally Advanced Breast Cancer Requiring Initial Mastectomy. Clin Breast Cancer 2015; 15:e231-5. [PMID: 25887149 DOI: 10.1016/j.clbc.2015.03.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Revised: 03/04/2015] [Accepted: 03/12/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND The aim of this study was to assess the rate of breast-conserving surgery (BCS) after neoadjuvant chemotherapy (nCT) in patients for whom mastectomy (MT) was, initially, the only conceivable surgical option. PATIENTS AND METHODS Between 2007 and 2012, 168 patients from a single center received nCT. Among these patients, we focused on the ones who received nCT (n = 119, [70.8%]) to decrease tumor size and thus to potentially allow a conservative surgical treatment. For these patients, MT was initially the only possible surgical treatment. RESULTS Among the 119 patients included, 118 presented with an invasive ductal carcinoma. The mean tumor size before nCT, measured using magnetic resonance imaging, was 41.6 mm (range, 15-110 mm) and 25.3 mm (range, 0-90 mm) after nCT. Eighty-six patients (72.3%) underwent BCS, and oncoplastic techniques were used in 29 patients (33.6%). Only 4.3% (5 patients) of patients who were treated with BCS needed additional surgery because of positive surgical margins. The median follow-up was 41.1 months (95% confidence interval [CI], 35.2-48.3). Five-year overall survival after BCS and MT were 77% (95% CI, 63-92) and 77% (95% CI, 63-95) respectively. Five-year disease-free survival after BCS and MT were 74% (95% CI, 64-86) and 59% (95% CI, 40-89) (not significant), respectively. CONCLUSION nCT for selective patients with "chemosensitive" breast tumor leads to a significant "MT to BCS" conversion rate. The type of surgery does not seem to affect the patient's overall and disease-free survival rates. Oncoplastic procedures can help to extend BCS after nCT.
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Affiliation(s)
- Emmanuel Barranger
- Département de chirurgie oncologique, Centre Antoine Lacassagne, Nice, France.
| | - Julie Antomarchi
- Département de chirurgie oncologique, Centre Antoine Lacassagne, Nice, France
| | - Emmanuel Chamorey
- Département de recherche Clinique et innovation et statistiques, Centre Antoine Lacassagne, Nice, France
| | - Constance Cavrot
- Département de chirurgie oncologique, Centre Antoine Lacassagne, Nice, France
| | - Bernard Flipo
- Département de chirurgie oncologique, Centre Antoine Lacassagne, Nice, France
| | - Philippe Follana
- Département d'oncologie médicale, Centre Antoine Lacassagne, Nice, France
| | - Isabelle Peyrottes
- Département d'anatomie-pathologique, Centre Antoine Lacassagne, Nice, France
| | | | - Jean Marc Ferrero
- Département d'oncologie médicale, Centre Antoine Lacassagne, Nice, France
| | - Tarik Ihrai
- Département de chirurgie oncologique, Centre Antoine Lacassagne, Nice, France
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Secuelas estéticas de la cirugía oncoplástica de la mama. Clasificación y principios para su prevención. Cir Esp 2015; 93:75-83. [DOI: 10.1016/j.ciresp.2014.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/10/2014] [Accepted: 06/11/2014] [Indexed: 11/23/2022]
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Emiroğlu M, Sert İ, İnal A. The Role of Oncoplastic Breast Surgery in Breast Cancer Treatment. THE JOURNAL OF BREAST HEALTH 2015; 11:1-9. [PMID: 28331682 PMCID: PMC5351526 DOI: 10.5152/tjbh.2014.2215] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 07/01/2014] [Indexed: 11/22/2022]
Abstract
The aim of this study is to discuss indications, advantages, disadvantages, oncologic and aesthetic results of Oncoplastic Surgery (OBS). Pubmed and Medline database were searched for articles published between 1998 and 2014 for keywords: oncoplastic breast surgery, therapeutic mammoplasty, oncoplastic breast reduction, synchrenous reconstructions. Role of OBS in breast cancer surgery, its aspects to be considered, its value and results have been interpreted. This technique has advantages by providing more extensive tumourectomy, yielding better aesthetic results compared with breast conserving surgery, allowing oncoplastic reduction in breast cancer patients with macromastia, with higher patient satisfaction and quality of life and by being inexpensive due to single session practice. As for its disadvantages are: re-excision is more difficult, risk for mastectomy is higher, it is depent on the Surgeron's experience, it has a risk for delay in adjuvant therapies and its requirement for additional imaging studies during management. Main indications are patients with small tumour/breast volume, macromastia, multifocality, procedures which can disrupt breast cosmesis such as surgeries for upper inner breas tquadrient tumours. Contraindications are positive margin problems after wide excision, diffuse malign microcalsifications, inflammatory breast cancer, history of radiotherapy and patients' preferences. Despite low evidence level, Oncoplastic Breast Surgery seems to be both reliable and acceptable in terms of oncologic and aesthetic aspects. Oncoplastic Breast Surgery increase the application rate of breast conserving surgery by obviating practical limitations and improve the results of breast conserving surgery. Correct patient and technique choice in OBS is vital for optimization of post surgical.
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Affiliation(s)
- Mustafa Emiroğlu
- Clinic of General Surgery, Tepecik Training and Research Hospital, İzmir, Turkey
| | - İsmail Sert
- Clinic of General Surgery, Tepecik Training and Research Hospital, İzmir, Turkey
| | - Abdullah İnal
- Clinic of General Surgery, Bursa Şevket Yılmaz Training and Research Hospital, Bursa, Turkey
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Tan V, Cornford E, McCulley S, Macmillan R. Qualitative mammographic findings and outcomes of surveillance mammography after partial breast reconstruction with an autologous flap. J Surg Oncol 2014; 111:377-81. [DOI: 10.1002/jso.23838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Accepted: 10/18/2014] [Indexed: 11/08/2022]
Affiliation(s)
- V.K. Tan
- Nottingham City Hospital; Nottingham United Kingdom
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Losken A, Pinell-White X, Hart AM, Freitas AM, Carlson GW, Styblo TM. The oncoplastic reduction approach to breast conservation therapy: benefits for margin control. Aesthet Surg J 2014; 34:1185-91. [PMID: 25121787 DOI: 10.1177/1090820x14545618] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Reduction mammaplasty during lumpectomy allows more generous resection and minimizes potential for poor cosmesis as compared with breast conservation therapy alone. OBJECTIVES The authors assessed the benefits of oncoplastic reduction for margin status in patients with breast cancer by conducting a retrospective review of cases of tumor resection alone vs tumor resection with oncoplastic reduction. METHODS Patients with breast cancer who underwent lumpectomy performed by a single oncologic surgeon between 2009 and 2013 were included. Patients were stratified into 2 groups based on surgical procedure: tumor resection with oncoplastic reduction (group 1) vs tumor resection alone (group 2). Patient demographics including risk factors, diagnosis, cancer stage, and procedure type were recorded. Tumor size, specimen weight, width of narrowest margin, and receptor status were determined. Outcome variables included margin positivity (≤1 mm), need for re-excision, and conversion to completion mastectomy. RESULTS A total of 222 breasts from 207 patients were included in the study: 83 in group 1 and 139 in group 2. The patients in group 1 had a lower incidence of positive margins and wider free surgical margins, required re-excision less often, and went on to completion mastectomy less often. Patients in group 1 were younger and had cancer that was more advanced. When controlling for these variables on multivariate regression analysis, the oncoplastic technique was independently associated with fewer positive margins and fewer instances of re-excision. CONCLUSIONS The oncoplastic reduction technique achieves wider free margins and less often necessitates re-excision or subsequent mastectomy. The long-term oncologic effect of this approach deserves further study. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Albert Losken
- Dr Losken is Program Director, Drs Pinell-White, Hart, and Freitas are residents, and Dr Carlson is Chief of the Division of Plastic Surgery; and Dr Styblo is Associate Professor of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Ximena Pinell-White
- Dr Losken is Program Director, Drs Pinell-White, Hart, and Freitas are residents, and Dr Carlson is Chief of the Division of Plastic Surgery; and Dr Styblo is Associate Professor of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Alexandra M Hart
- Dr Losken is Program Director, Drs Pinell-White, Hart, and Freitas are residents, and Dr Carlson is Chief of the Division of Plastic Surgery; and Dr Styblo is Associate Professor of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Alessandrina M Freitas
- Dr Losken is Program Director, Drs Pinell-White, Hart, and Freitas are residents, and Dr Carlson is Chief of the Division of Plastic Surgery; and Dr Styblo is Associate Professor of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Grant W Carlson
- Dr Losken is Program Director, Drs Pinell-White, Hart, and Freitas are residents, and Dr Carlson is Chief of the Division of Plastic Surgery; and Dr Styblo is Associate Professor of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
| | - Toncred M Styblo
- Dr Losken is Program Director, Drs Pinell-White, Hart, and Freitas are residents, and Dr Carlson is Chief of the Division of Plastic Surgery; and Dr Styblo is Associate Professor of Surgery, Division of Surgical Oncology, Emory University, Atlanta, Georgia
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Abstract
UNLABELLED When immediate reconstruction is applied to breast conservation therapy (BCT), the benefits extend well beyond the minimization of poor cosmetic results. The purpose of this analysis was to compare literature outcomes between BCT alone and BCT with the oncoplastic approach. METHODS A meta-analysis was performed in PubMed using key words "oncoplastic," "partial breast reconstruction," and "breast conservation therapy." Case reports, series with less than 10 patients, and those with less than 1-year follow-up were excluded from the analysis. The 3 comparative groups included BCT with oncoplastic reduction techniques (Group A), BCT with oncoplastic flap techniques (Group B), and BCT alone (Group C). RESULTS Comparisons were made on 3165 patients in the BCT with oncoplastic group (Groups A and B, 41 papers) and 5494 patients in the BCT alone group (Group C, 20 papers). Demographics were similar, and tumor size was larger in the oncoplastic group (2.7 vs 1.2 cm). The weight of the lumpectomy specimen was 4 times larger in the oncoplastic group. The positive margin rate was significantly lower in the oncoplastic group (12% vs 21%, P < 0.0001). Reexcision was more common in the BCT alone group (14.6% vs 4%, P < 0.0001), however, completion mastectomy was more common in the oncoplastic group (6.5% vs 3.79%, P < 0.0001). The average follow-up was longer in the BCT alone group (64 vs 37 months). Local recurrence was 4% in the oncoplastic group and 7% in the BCT alone group. Satisfaction with the aesthetic outcome was significantly higher in the oncoplastic group (89.5% vs 82.9%, P < 0.001). CONCLUSIONS The oncoplastic approach to BCT allows a generous resection with subsequent reduction in positive margins. The true value on local recurrence remains to be determined. Patients are more satisfied with outcomes when the oncoplastic approach is used.
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Kaviani A, Safavi A, Mohammadzadeh N, Jamei K, Ansari-Damavandi M, Salmon RJ. Oncoplastic surgery in breast conservation: a prospective evaluation of the patients, techniques, and oncologic outcomes. Am J Surg 2014; 208:727-734. [PMID: 25042578 DOI: 10.1016/j.amjsurg.2014.04.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 04/24/2014] [Accepted: 04/29/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND The oncologic efficacy of breast-conserving therapies has been established in recent decades. Oncoplastic breast surgery (OBS), as a leap forward in breast conservation, offers concomitant techniques of oncologic and plastic surgeries that grant better esthetic results. The outcomes of our oncoplastic surgeries from 2007 to 2012 are reported. METHODS A series of 258 cases with breast masses (18 benign and 240 carcinomas) were operated on by OBS techniques and prospectively followed. Neoadjuvant and adjuvant oncologic treatments were also delivered as indicated. RESULTS Free margins were obtained in 95% of cancer patients. During the 26 months of follow-up, local recurrence happened in 7 (2.9%) patients, of which 1 underwent oncologic therapies and 6 underwent completion mastectomy. Complications postponed adjuvant therapies in 3 (1.2%) patients. Postsurgically, metastases were diagnosed in 8 (3.3%) patients. Two patients (.8%) died of cancer. CONCLUSIONS Outcomes of OBS are oncologically acceptable with low frequencies of positive margins and recurrence, while cosmetic results are much improved by OBS.
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Affiliation(s)
- Ahmad Kaviani
- Department of Surgery, Tehran University of Medical Sciences (TUMS), P.O. Box 13145-158, Tehran, Iran; Department of Research, Kaviani Breast Diseases Institute (KBDI), P.O. Box 14358-6443, Tehran, Iran.
| | - Amin Safavi
- Department of Surgery, Tehran University of Medical Sciences (TUMS), P.O. Box 13145-158, Tehran, Iran; Department of Research, Kaviani Breast Diseases Institute (KBDI), P.O. Box 14358-6443, Tehran, Iran
| | - Narjes Mohammadzadeh
- Department of Surgery, Tehran University of Medical Sciences (TUMS), P.O. Box 13145-158, Tehran, Iran
| | - Khatereh Jamei
- Department of Research, Kaviani Breast Diseases Institute (KBDI), P.O. Box 14358-6443, Tehran, Iran
| | - Maryam Ansari-Damavandi
- Department of Research, Kaviani Breast Diseases Institute (KBDI), P.O. Box 14358-6443, Tehran, Iran
| | - Remy J Salmon
- Hôpital des Peupliers, 80 Rue de la Colonie, Paris 75013, France
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Quality of information reporting in studies of standard and oncoplastic breast-conserving surgery. Breast 2013; 23:104-11. [PMID: 24388734 DOI: 10.1016/j.breast.2013.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 11/30/2013] [Accepted: 12/07/2013] [Indexed: 11/20/2022] Open
Abstract
The aim of this systematic review was to establish the completeness of reporting of key patient, tumour, treatment, and outcomes information in the randomized-controlled trials (RCTs) of standard breast-conserving surgery (sBCS) considered to be the 'gold-standard', and to compare this with the reporting of the same key criteria for all published studies of oncoplastic breast-conserving surgery (oBCS). Pubmed (1966 to 1st April 2013), Ovid MEDLINE (1966 to 1st April 2013), EMBASE (1980 to 1st April 2013), and the Cochrane Database of Systematic Reviews (Issue 4, 2013) were searched separately for the following terms: (i) 'oncoplastic AND breast AND surgery'; and (ii) 'therapeutic AND mammaplasty'. Only English language and full text articles were reviewed. Following a pilot evaluation of all studies, key reporting criteria were identified. 16 RCTs of sBCS (n = 11,767 patients) were included, and 53 studies met the inclusion criteria for oncoplastic BCS (n = 3236 patients), none of which were RCTs. No study reported all of the criteria identified, with a mean of 64% of key criteria (range, 55-75%) reported in studies of sBCS, and 54% of criteria (range, 10-85%) reported in studies of oBCS. It is therefore evident that there is much room for improvement in the quality of reporting is BCS studies. Standards are proposed to give future studies of BCS a framework for reporting key information and outcomes.
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Mazouni C, Naveau A, Kane A, Dunant A, Garbay JR, Leymarie N, Sarfati B, Delaloge S, Rimareix F. The role of oncoplastic breast surgery in the management of breast cancer treated with primary chemotherapy. Breast 2013; 22:1189-93. [PMID: 24054903 DOI: 10.1016/j.breast.2013.07.055] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 07/04/2013] [Accepted: 07/20/2013] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The purpose of this study was to evaluate the benefit of Oncoplastic Breast Conserving Surgery (BCS) compared to standard BCS after primary CT, in terms of oncologic safety and cosmetic outcomes. BACKGROUND The development of new drugs has led to greater use of primary chemotherapy (CT) for bulky breast cancer (BC) and has allowed wider indications for conservative surgery. PATIENTS AND METHODS We identified 259 patients consecutively treated with BCS for primary BC from January 2002 to November 2010. All patients had undergone Oncoplastic Breast Surgery (OBS) or standard BCS after primary CT. Mastectomy rates, and oncological and cosmetic outcomes were compared. RESULTS A total of 45 OBS and 214 standard BCS were analyzed. The median tumor size was 40 mm in the two groups (p = 0.66). The median operative specimen volumes were larger in the OBS group than in the standard group (respectively, 180 cm3 and 98 cm3, p < 0.0001). Re-excision (9% vs. 2%) and mastectomy (24% vs. 18%) rates were similar (p = 0.22 and p = 0.30) in the standard BCS group and in the OBS group respectively. At a median follow-up of 46 months, local relapse (p = 0.23) and distant relapse (p = 0.35) rates were similar. CONCLUSION OBS allows excision of larger volumes of residual tumor after primary CT. OBS outcomes results were similar to those of standard BCS. Oncoplastic Breast Conserving Surgery (BCS) after primary chemotherapy allows wider breast resection than standard BCS. Survival and relapse probabilities are similar in both groups.
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Affiliation(s)
- Chafika Mazouni
- Department of Breast and Plastic Surgery, Institut Gustave Roussy, Villejuif, France.
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Pompei S, Marcasciano F, Frascino LF, Cesarini C, Labardi L, Caravelli G, Abate O, Arelli F. The inferior pedicle flap used as “filler” in breast conservative therapy. EUROPEAN JOURNAL OF PLASTIC SURGERY 2012. [DOI: 10.1007/s00238-012-0760-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Grubnik A, Benn C, Edwards G. Therapeutic Mammaplasty for Breast Cancer: Oncological and Aesthetic Outcomes. World J Surg 2012; 37:72-83. [DOI: 10.1007/s00268-012-1786-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Zucca Matthes AG, Uemura G, Kerr L, Matthes ÂCS, Michelli RAD, Folgueira MAAK, da Costa Viera RA. Feasibility of oncoplastic techniques in the surgical management of locally advanced breast cancer. Int J Surg 2012; 10:500-5. [PMID: 22858800 DOI: 10.1016/j.ijsu.2012.07.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Revised: 07/17/2012] [Accepted: 07/22/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Locally advanced breast cancer (LABC) is still common in developing countries. The association between neoadjuvant chemotherapy (NC) and oncoplastic surgery (OS) might provide an oncological treatment with satisfactory aesthetic results. PURPOSE The goal was to demonstrate if oncoplastic surgical techniques can be utilized to treat LABC which was submitted to neoadjuvant chemotherapy. METHODS This prospective clinical trial included breast cancer patients, clinical stage III, who underwent established NC regimen. All patients underwent preoperative planning to control the tumor size and to define the surgical technique. A detailed analysis of the pathological specimen was performed. RESULTS 50 patients were assessed and surgically treated. Tumor size ranged from 3.0 to 14.0 cm (median 6.5 cm). Pathologic response was rated as stable, progressive, partial response, and complete response in 10%, 8%, 80% and 2% of the cases, respectively. Seventeen (34%) patients were submitted to OS. No patient had positive margins. Skin involvement was presented in 36% of pathologic specimen. CONCLUSIONS Oncoplastic surgical techniques for selected patients decrease the rates of radical surgery despite large tumors. (www.clinicaltrials.gov, NCT00820690).
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Affiliation(s)
- Angelo Gustavo Zucca Matthes
- Department of Gynaecology, Obstetrics and Mastology, School of Medicine of Botucatu, UNESP-Distrito de Rubião Júnior, Botucatu-SP, Brazil.
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Khafagy M, Fakhr I, Hamed A, Youssef O. Pedicled dermoglandular flap reconstruction following breast conserving surgery. J Egypt Natl Canc Inst 2012; 24:91-6. [DOI: 10.1016/j.jnci.2012.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 04/25/2012] [Accepted: 05/01/2012] [Indexed: 11/17/2022] Open
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McIntosh J, O'Donoghue J. Therapeutic mammaplasty – A systematic review of the evidence. Eur J Surg Oncol 2012; 38:196-202. [DOI: 10.1016/j.ejso.2011.12.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 11/15/2011] [Accepted: 12/12/2011] [Indexed: 10/14/2022] Open
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Hernanz F, Sánchez S, Cerdeira MP, Figuero CR. Long-term results of breast conservation and immediate volume replacement with myocutaneous latissimus dorsi flap. World J Surg Oncol 2011; 9:159. [PMID: 22142459 PMCID: PMC3286394 DOI: 10.1186/1477-7819-9-159] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 12/05/2011] [Indexed: 11/23/2022] Open
Abstract
Background Published long-term outcomes of oncoplastic breast-conserving surgery are scarce and, specifically, aesthetic outcomes assessed with an objective method have not previously been published. Methods A cohort of 41 patients treated with a quadrantectomny and immediate reconstruction using a myocutaneous latissimus dorsi flap were analyzed and their aesthetic outcomes were evaluated objectively by BCCT.core software. Results At the end of a 58-month follow-up from the date of initial diagnosis, one patient (2.4%) developed an ipsilateral recurrence, six patients developed distant metastases and three patients died (7.3%) without ipsilateral recurrence, one of them presenting hepatic metastases at the time of the initial diagnosis. We were able to evaluate aesthetic results in 23 patients, 3 assessed as excellent, 12 good and 8 fair. Conclusion This oncoplastic volume replacement technique obtained a good local control and satisfactory and stable aesthetic results which have maintained unchanged after a long period of time.
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Affiliation(s)
- Fernando Hernanz
- Breast Unit, Hospital, University of Cantabria, Marqués de Valdecilla (Avda Valdecilla s/n), Santander, (39008), Cantabria, Spain.
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Dickson-Witmer D, Bleznak AD, Kennedy JS, Stewart AK, Palis BE, Bailey L, Laidley AL, Penman EJ. Breast Cancer Care in the Community: Challenges, Opportunities, and Outcomes. Surg Oncol Clin N Am 2011; 20:555-80, ix. [DOI: 10.1016/j.soc.2011.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sakr R, Poulet B, Kaufman G, Nos C, Clough K. Clear margins for invasive lobular carcinoma: A surgical challenge. Eur J Surg Oncol 2011; 37:350-6. [DOI: 10.1016/j.ejso.2011.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2010] [Revised: 12/29/2010] [Accepted: 01/06/2011] [Indexed: 11/27/2022] Open
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Abstract
As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.
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Abstract
The role of the breast cancer surgeon has changed from one with performance of one operation, to a position in which the surgeon is the patient's initial contact, leader of a multidisciplinary team, the clinical leader who ensures that the patient receives the most appropriate breast cancer treatment and then also receives follow up and surveillance services. Breast conservation rates, patient satisfaction rates, clear margins, use of oncoplastic surgical techniques, appropriate referral to other consultants, clinical trial referral, and survival rates are all higher when patients are cared for by breast-focused surgeons. This new role requires greater time both before and after surgery to provide the proper planning and care for these patients. Women with breast cancer should have access to these dedicated breast-focused surgeons. Recognition of this expanding responsibility and reimbursement for this time and expertise is needed so that women with breast cancer can be offered the highest quality of care.
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