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)

Clinical and patient-reported outcomes in women offered oncoplastic breast-conserving surgery as an alternative to mastectomy: ANTHEM multicentre prospective cohort study

BACKGROUND

Oncoplastic breast-conserving surgery may be a better option than mastectomy, but high-quality comparative evidence is lacking. The aim of the ANTHEM study (ISRCTN18238549) was to explore clinical and patient-reported outcomes in a multicentre cohort of women offered oncoplastic breast-conserving surgery as an alternative to mastectomy with or without immediate breast reconstruction.

METHODS

Women with invasive/pre-invasive breast cancer who were offered oncoplastic breast-conserving surgery with volume replacement or displacement techniques to avoid mastectomy were recruited prospectively. Demographic, operative, oncological, and 3- and 12-month complication data were collected. The proportion of women choosing oncoplastic breast-conserving surgery and the proportion in whom breast conservation was successful were calculated. Participants completed the validated BREAST-Q questionnaire at baseline, 3 months after surgery, and 12 months after surgery. Questionnaires were scored according to the developers' instructions and scores for each group were compared over time.

RESULTS

In total, 362 women from 32 UK breast units participated, of whom 294 (81.2%) chose oncoplastic breast-conserving surgery. Of the oncoplastic breast-conserving surgery patients in whom postoperative margin status was reported, 210 of 255 (82.4%) had clear margins after initial surgery and only 10 (3.9%) required completion mastectomy. Major complications were significantly more likely after immediate breast reconstruction. Women having oncoplastic breast-conserving surgery with volume displacement techniques reported significant improvements in baseline 'satisfaction with breasts' and 'psychosocial well-being' scores at 3 and 12 months, but both oncoplastic breast-conserving surgery groups reported significant decreases in 'physical well-being: chest' at 3 and 12 months.

CONCLUSION

Oncoplastic breast-conserving surgery allows greater than 95% of women to avoid mastectomy, with lower major complication rates than immediate breast reconstruction, and may improve satisfaction with outcome. Oncoplastic breast-conserving surgery should be offered as an alternative to mastectomy in all women in whom it is technically feasible.

Understanding decision-making for and against oncoplastic breast-conserving surgery as an alternative to a mastectomy in early breast cancer: UK ANTHEM qualitative study

BACKGROUND

Oncoplastic breast-conserving surgery may allow women with early breast cancer to avoid a mastectomy, but many women undergo more extensive surgery, even when breast-conserving options are offered. The aim of the ANTHEM qualitative study was to explore factors influencing women's surgical decision-making for and against oncoplastic breast-conserving surgery.

METHODS

Semi-structured interviews were conducted with a purposive sample of women who had received either oncoplastic breast-conserving surgery or a mastectomy with or without immediate breast reconstruction to explore their rationale for procedure choice. Interviews were transcribed verbatim and analysed thematically. Trial registration number: ISRCTN18238549.

RESULTS

A total of 27 women from 12 centres were interviewed. Out of these, 12 had chosen oncoplastic breast-conserving surgery and 15 had chosen a mastectomy with or without immediate breast reconstruction. Overwhelmingly, women's decisions were guided by their surgical teams. Decision-making for and against oncoplastic breast-conserving surgery was influenced by three key inter-related factors: perceptions of oncological safety; the importance of maintaining/restoring femininity and body image; and practical issues. Oncological safety was paramount. Women who reported feeling reassured that oncoplastic breast-conserving surgery was oncologically safe were happy to choose this option. Those who were not reassured were more likely to opt for a mastectomy, as a perceived 'safer' option. Most women wished to maintain/restore femininity, with the offer of immediate breast reconstruction essential to make a mastectomy an acceptable option. Practical issues such as the perceived magnitude of the surgery were a lesser concern.

CONCLUSION

Decision-making is complex and heavily influenced by the surgical team. High-quality, accurate information about surgical options, including appropriate reassurance about the short- and long-term oncological safety of oncoplastic breast-conserving surgery is vital if women are to make fully informed decisions.

Current practice and provision of oncoplastic breast-conserving surgery in the UK: results of the ANTHEM national practice questionnaire

PURPOSE

Oncoplastic breast-conserving surgery (OPBCS) may be a better option than mastectomy ± immediate breast reconstruction (IBR) for women with breast cancer but studies directly comparing the techniques are lacking. We surveyed UK breast units to determine the current practice of OPBCS to inform the design of a future comparative study.

METHODS

An electronic survey was developed to explore the current practice of OPBCS. This included the local availability of volume displacement and/or replacement techniques; number of cases performed; contraindications and approach to contralateral symmetrisation. Summary data for each survey item were calculated and overall provision of care examined.

RESULTS

58 UK centres completed the survey, including 43 (74%) stand-alone breast and 15 (26%) combined breast/plastics units. Over 40% of units (n = 24) treated more than 500 cancers/year. Most units offered volume displacement techniques (TMs) (97%). Over two-thirds (n = 39. 67%) of units offered local perforator flaps (LPF). Approximately a half of units (10/19) not performing LPF were planning to introduce them in the next 12-24 months. A third (n = 19, 33%) of units routinely performed simultaneous contralateral symmetrisation mostly with two-surgeon operating. There were limited oncological restrictions to OPBCS with no contraindications for multifocal cancers in most centres; 65% of units (36/55) offered OPBCS for multicentric disease. Extensive DCIS was a contraindication in a minority of units.

CONCLUSIONS

OPBCS is widely available in the UK but contraindications and approaches to contralateral symmetrisation were variable. Work is now needed to prospectively evaluate the outcomes of OPBCS vs mastectomy ± IBR to support informed decision-making.

A Machine Vision Anomaly Detection System to Industry 4.0 Based on Variational Fuzzy Autoencoder

From a technological point of view, Industry 4.0 evolves and operates in a smart environment in which the real and virtual worlds come together through smart cyber-physical systems. These devices that control each other autonomously activate innovative functions that enhance the production process. However, the industrial environment in which the most modern digital automation and information technologies are integrated is an ideal target for large-scale targeted cyberattacks. Implementing an integrated and effective security strategy in the Industrial 4.0 ecosystem presupposes a vertical inspection process at regular intervals to address any new threats and vulnerabilities throughout the production line. This view should be accompanied by the deep conviction of all stakeholders that all systems of modern industrial infrastructure are a potential target of cyberattacks and that the slightest rearrangement of mechatronic systems can lead to generalized losses. Accordingly, given that there is no panacea in designing a security strategy that fully ensures the infrastructure in question, advanced high-level solutions should be adopted, effectively implementing security perimeters without direct dependence on human resources. One of the most important methods of active cybersecurity in Industry 4.0 is the detection of anomalies, i.e., the identification of objects, observations, events, or behaviors that do not conform to the expected pattern of a process. The theme of this work is the identification of defects in the production line resulting from cyberattacks with advanced machine vision methods. An original variational fuzzy autoencoder (VFA) methodology is proposed. Using fuzzy entropy and Euclidean fuzzy similarity measurement maximizes the possibility of using nonlinear transformation through deterministic functions, thus creating an entirely realistic vision system. The final finding is that the proposed system can evaluate and categorize anomalies in a highly complex environment with significant accuracy.

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.

Systematic Review of Breast-Q: A Tool to Evaluate Post-Mastectomy Breast Reconstruction

Purpose

The aim of this systematic review is to update and synthesize new evidence on BREAST-Q questionnaire’s ability to reflect patient-reported outcomes in women who have undergone breast reconstruction surgery (BRS) following mastectomy.

Methods

PubMed, Science Direct, Google Scholar, Cochrane CENTRAL, and Clincaltrial.gov were searched for relevant studies from January 2009 to September 2021. Any interventional or observational studies that used BREAST-Q to assess patient-reported outcomes in the assessment of BRS following mastectomy were included.

Results

A total of 42 studies were eligible for inclusion in the review. Three were randomized controlled trials and 39 were observational studies. Compared with pre-operative scores, there was an improvement in all BREAST-Q outcome domains following BRS including ‘satisfaction with breasts’, “satisfaction with outcome” “psychosocial”, “physical”, and “sexual wellbeing”. Sexual well-being had the lowest BREAST-Q score both pre-and post-operatively (37.8–80.0 and 39.0–78.0, respectively). Autologous BRS reports higher satisfaction and overall wellbeing compared to implant-based BRS. BREAST-Q has a higher and narrow internal consistency of 0.81 to 0.96 compared with other patient-reported outcome measures (PROMs; EORTC-QLQ, FACT-B, BR-23, BCTOS). The BREAST-Q questionnaire is the only PROM which allows patients to reflect on their care, surgical outcomes, and satisfaction collectively.

Conclusion

This review highlights the fact that BREAST-Q can effectively and reliably measure satisfaction and wellbeing of breast cancer patients after BRS. Comparatively, sexual wellbeing shows poorer outcomes following BRS and more longitudinal studies are necessary to understand the basis for these findings. Compared to other PROMs, BREAST-Q is reliable and specific to breast cancer surgery. Overall, BREAST-Q can help clinicians improve their quality of service, understand patient experiences, and may be used as an auditing tool for surgical outcomes.

Update on oncoplastic techniques in breast conserving surgery: algorithms for predictable results and custom-made reconstructions

Breast cancer surgery is going to be a relevant specialty involved in the multidisciplinary disease management, finalized to guarantee high performances on mortality reduction together with a quality of life improvement. The intellectual architecture of this field is characterized by its inclination to respect, sharing, empathy and scientific knowledge that can make it a high model of medical culture. In this context, oncoplastic breast conserving surgery is identified by special aesthetic sensitivities, as well as creativity and innovation. Knowing how to reshape the gland and fill the gaps, planning the targeted exeresis design, while anticipating the final outcome, respecting symmetries and ensuring first of all oncological safety, are the new skills that are required to the breast surgeon. Several tecniques could provide a refined surgical treatment but always challenging according to anatomical findings and patient expectations, as a systematic process of self-critical reflection, with the purpose to optimize criteria for improving therapeutic results.