Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q™

A Clinical Analysis of Prognosis and Patient-Reported Outcomes of Oncoplastic Breast-Conserving Surgery for Early Breast Cancer: A Retrospective Cohort Study

PURPOSE

Approximately 25-30% of patients suffer from breast deformity and/or asymmetry after conventional breast-conserving surgery (CBCS). Generally, it is thought that oncoplastic breast-conserving surgery (OBCS) results in an improved cosmetic result; however, studies comparing the prognosis and aesthetic outcomes of CBCS and OBCS in early breast cancer (EBC) are inadequate.

METHODS

A total of 143 patients were included in this retrospective cohort study; 53 underwent OBCS and 90 underwent CBCS. The resected weight, complications, esthetic results, patient satisfaction, and recurrence rate were compared between the groups. Patient-reported outcomes (PRO) were assessed by the BREAST-Q questionnaire.

RESULTS

The mean age of the patients in OBCS group was 43.8 years. This was younger than that in CBCS group (49.1 years, p < 0.001). Postoperative complications (11.3% vs. 8.9%, p = 0.64) and re-excision (5.7% vs. 6.7%, p > 0.99) rates were similar. The OBCS group had higher breast satisfaction and psychosocial well-being than the CBCS group (75 vs. 63, p < 0.001 and 84 vs. 77, p = 0.05); however, sexual well-being (56 vs. 66, p = 0.05) and physical well-being (65 vs. 76, p < 0.001) were worse in OBCS. After 42.3 (range: 12.6-69.2)-month median follow-up, no difference in event-free survival (EFS) was demonstrated between the groups (p = 0.13).

CONCLUSION

Although OBCS has the better aesthetic outcomes and identical oncological safety in comparison with CBCS, the sexual and physical well-being in OBCS are not improved for Asian patients. Hence, choosing an appropriate procedure may be more important for the typically small to moderate-sized breasts characteristic of Asian females unlike Westerners.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?

INTRODUCTION

Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described.

OBJECTIVE

We aimed to compare the costs of eOBCS and mastectomy.

METHODS

We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included.

RESULTS

Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416.

CONCLUSION

eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.

Health-related quality of life by type of breast surgery in women with primary breast cancer: prospective longitudinal cohort study

BACKGROUND

Health-related quality of life and patient-related outcome measures for patients with cancer have gained increased interest over the last decade. However, few prospective studies with longitudinal data evaluated health-related quality of life in patients with breast cancer. This study aimed to investigate how health-related quality of life changed from the time of diagnosis to 1 year after breast cancer surgery for the main surgical techniques.

METHODS

This prospective longitudinal single-centre study included patients with primary breast cancer diagnosed in 2019-2020 who underwent surgery. Patients completed a health-related quality of life questionnaire (Breast-Q) at baseline. One year after surgery, they completed the Breast-Q a second time, the EORTC (European Organization for Research and Treatment of Cancer) quality of life questionnaire-C30 and the quality of life questionnaire-BR23. Analysis of variance and Kruskal-Wallis tests were used to evaluate the differences in health-related quality of life between surgical groups. Analysis of covariance with robust standard errors was used to adjust for confounders.

RESULTS

In total, 340 patients were included in the study; 160 patients received oncoplastic partial mastectomy, 112 received partial mastectomy, 42 received mastectomy and 26 had mastectomy with immediate reconstruction. Patients that had partial mastectomy or oncoplastic partial mastectomy were more satisfied with their breasts (P < 0.001), had a better body image (P = 0.006) and higher sexual functioning scores (P = 0.027) than patients who had a mastectomy with/without reconstruction. The oncoplastic and mastectomy with reconstruction groups had more breast symptoms than other groups (P < 0.001), and the mastectomy group had the least symptoms from the chest area.

CONCLUSION

Partial mastectomy and oncoplastic partial mastectomy have the best outcomes in terms of breast satisfaction, body image and sexual functioning. This highlights the importance of preserving the breast when feasible and underscores that breast reconstruction is not equal to breast conservation. Registration number: NCT04227613 (http://www.clinicaltrials.gov).

How do women perceive their breast image before and after bilateral therapeutic mammoplasty for early breast cancer?

INTRODUCTION

Bilateral therapeutic mammoplasty (BTM) is commonly performed in the UK during treatment for breast cancer, and the available data show oncological safety. This study aims to compare patient-recorded outcome measures before and after surgery, as well as associated patient factors.

METHODS

Between March 2018 and December 2019, patients undergoing BTM for breast cancer completed validated BREAST-Q reduction modules before and 3 months after surgery and a radiotherapy domain at 3 months. Scores were correlated with clinical data. For BREAST-Q scales, a higher score (0-100) represents greater satisfaction or quality of life.

RESULTS

28 patients were included, median age 58 years (IQR 52-64), BMI 32.0 (IQR 27.8-34.0). Of these, 1 had bilateral disease, 2 had multifocal disease, and the remaining had unilateral disease. Most (55%) underwent Wise pattern incision. At 3 months post-operatively, the following outcome scores improved based on the Wilcoxon signed-rank test: satisfaction with breasts (median 44 to 84; p < 0.001), psychosocial wellbeing (57.5 to 83; p < 0.001) and sexual wellbeing (48 to 61; p = 0.029). The improvement in satisfaction with breasts score correlated with the preoperative score (p = 0.011), with a larger increase in patients with a lower baseline score. Physical wellbeing was unchanged overall (median 71 to 72). In all solely post-operative domains (satisfaction with information, outcome, nipples and following radiation), patients reported high levels of satisfaction with outcomes.

CONCLUSIONS

Patients reported improved levels of patient-related quality of life measures after therapeutic mammoplasty, including satisfaction with breasts and psychosocial and sexual wellbeing, with high post-operative outcomes in satisfaction with outcome, information and nipples, as well as radiation Q-score.

Oncoplastic breast-conserving surgery (OBCS) vs. mastectomy with reconstruction: a comparison of outcomes in an underserved population

Background

Oncoplastic breast-conserving surgery (OBCS) has demonstrated superior cosmetic outcomes to traditional breast-conserving surgery (BCS) while maintaining oncologic safety. While prior studies have compared OBCS to mastectomy, there is a scarcity of literature on the impact of social determinants of health on outcomes. Furthermore, although traditionally tumors larger than 5 cm and multifocal disease were treated with mastectomy, the literature has now shown OBCS to be safe in treating such disease. As a result, patients with large or multifocal tumors could be eligible for both mastectomy and OBCS, which prompts the need for comparison between the two. Thus, the aim of our study was to compare OBCS and mastectomy with reconstruction using BREAST-Q and oncologic outcome measures, as well as stratify these outcomes based on race, ethnicity, and body mass index (BMI).

Methods

A retrospective chart review was performed for 57 patients treated with OBCS and 204 patients treated with mastectomy with reconstruction from 2015 to 2021. Variables including age, race, ethnicity, BMI, insurance status, surgery type, pathology, recurrence, and complications were recorded. Patient-reported outcomes (PROs) were recorded using BREAST-Q pre- and post-operatively.

Results

Despite having a higher BMI (P<0.001), OBCS yielded higher "satisfaction with breast" and "satisfaction with outcome" than mastectomy (P=0.02 and P=0.02, respectively). When stratified by race, there were no statistical differences in the PROs between the two surgeries for Hispanic nor African American patients. OBCS had a significantly lower rate of infection and fewer additional surgeries than mastectomy (P=0.004 and P<0.001, respectively). There were no differences in positive margin rate or recurrence rate between the groups.

Conclusions

In our study, OBCS yielded better PROs than mastectomy while maintaining oncologic safety and resulting in fewer surgeries and complications. These excellent outcomes in a majority non-Caucasian cohort support the utilization of OBCS for underserved, minority populations. Larger studies evaluating PROs in diverse and uninsured groups are needed to reinforce these conclusions.

Evolution of breast conserving surgery-current implementation of oncoplastic techniques in breast conserving surgery: a literature review

Background and Objective

De-escalation in breast cancer surgery has been a natural evolution since breast conserving surgery (BCS) was introduced in the early 1980s. From Halsted mastectomies to wide local excisions, we are facing nowadays the next trend in form of oncoplastic breast surgery. Oncoplastic breast surgery combines oncological principles with plastic surgery techniques to preserve the breast shape and appearance. The aim of this work is to review recent oncological and quality of live outcomes derived from oncoplastic techniques as well as offer a perspective about its implementation in breast cancer units.

Methods

A literature review was conducted to explore the landscape of oncoplastic breast surgery. Key terms related to oncoplastic techniques and breast cancer were used in searches across databases such as PubMed, Embase and Cochrane Library. Inclusion criteria focused on recent articles discussing oncological and quality of life (QoL) outcomes, as well as perspectives on the role of oncoplastic surgery.

Key Content and Findings

The research aims to contribute valuable insights into the efficacy and impact of oncoplastic surgery in the context of breast cancer treatment. In this new era of precision medicine, it is more than just healing patients; it is about improving their well-being. We ought to consider specific oncoplasty role in leading this paradigm shift. It is also relevant to define whether these new technical-demanding surgical options can be applied to all patients and if professional training performs adequately to current demands of personalized treatments.

Conclusions

The global adoption of oncoplastic BCS is recommended due to its oncological safety and improvement in QoL compared to standard procedures. Emphasizing the need for skilled surgeons in complex cases, collaboration between breast surgeons and scientific societies is urged to certify ongoing educational training in oncoplastic techniques.

Clinical outcomes and patient-reported outcomes after oncoplastic breast surgery in breast cancer patients: A matched cohort study

BACKGROUND

Surgery is the recommended treatment for breast cancer, the most common cancer in women in Taiwan and the leading cause of cancer-related deaths. Although breast-conserving surgery (BCS) has good prognosis, in some cases, BCS may cause more significant deformities and interfere with the patient's psychosocial well-being. Oncoplastic breast surgery (OBS) is the treatment option in these cases. This study aimed to determine the outcomes of OBS and BCS regardless of clinical and patient-reported esthetic outcomes.

METHODS

Between 2015 and 2020, 50 patients who underwent OBS at our hospital after complete treatment were enrolled. With 1:2 matched ratios, 100 patients were enrolled in the BCS control group. Clinical outcomes were analyzed. The BREAST-Q questionnaire was then assessed 6 months after the completion of treatment for subjective patient-reported outcomes.

RESULTS

Due to the matching process, no difference was noted between the two groups in terms of demographic data such as age, comorbidities, or tumor characteristics. There were no significant differences in the local recurrence rate, disease-free survival, overall survival, positive margin rate, rewide excision rate, conversion to mastectomy rate, or complication rate (major or minor) between both groups. However, the OBS group showed higher satisfaction with breasts in the BREAST-Q questionnaire ( p < 0.001). The mean follow-up time was 38.77 ± 14.70 months in the BCS group and 29.59 ± 14.06 months in the OBS group.

CONCLUSION

OBS seems to be a safe and feasible surgery in breast cancer patients because clinical outcomes are compatible with BCS. Moreover, the OBS group had better patient-reported outcomes in terms of satisfaction.

Simultaneous Symmetry Procedure in Patients Undergoing Oncoplastic Breast-Conserving Surgery: An Evaluation of Patient Desire and Revision Rates

INTRODUCTION

In the era of oncoplastic breast conserving-surgery (OBCS), cosmetic outcomes and the desire for symmetry have become essential elements of the surgical management of breast cancer (BC). The timing of contralateral symmetry procedures remains a controversial topic. Simultaneous symmetry procedures (SSP) in OBCS have not been routinely offered due to the perceived risk of delayed asymmetry, potentially increasing the need for delayed cosmetic revision. This study evaluates the rate of revision after SSP in patients undergoing OBCS.

METHODS

We reviewed our institutional prospectively maintained database identifying all BC patients treated surgically since our introduction of oncoplastic surgery in 2018. We routinely offer SSP when appropriate. Descriptive statistics evaluated oncoplastic surgical techniques, SSP offerings and procedures, perioperative complications, and revision rates after treatment completion.

RESULTS

Between 2018 and 2022, 485 breast cancer patients underwent partial mastectomy, and 396 (82%) underwent OBCS. Of the 313 patients offered SSP, 272 (87%) accepted. The margin reexcision rate of this cohort was 20%. Of the 272 patients with SSP, 152 (56%) underwent intraoperative radiation therapy (IORT), and 105 (39%) had adjuvant external beam radiation therapy. Three patients (1%) experienced complications involving the symmetry side. No patients with complications experienced a delay in adjuvant therapies or requested cosmetic revisions. Three patients (1%) desired surgical revisions due to asymmetry.

CONCLUSIONS

Symmetry procedures at the time of OBCS are widely accepted by patients and rarely require delayed cosmetic revision. Simultaneous symmetry procedures should be routinely discussed with patients during the surgical planning of OBCS.

Computational mechanobiology model evaluating healing of postoperative cavities following breast-conserving surgery

Breast cancer is the most commonly diagnosed cancer type worldwide. Given high survivorship, increased focus has been placed on long-term treatment outcomes and patient quality of life. While breast-conserving surgery (BCS) is the preferred treatment strategy for early-stage breast cancer, anticipated healing and breast deformation (cosmetic) outcomes weigh heavily on surgeon and patient selection between BCS and more aggressive mastectomy procedures. Unfortunately, surgical outcomes following BCS are difficult to predict, owing to the complexity of the tissue repair process and significant patient-to-patient variability. To overcome this challenge, we developed a predictive computational mechanobiological model that simulates breast healing and deformation following BCS. The coupled biochemical-biomechanical model incorporates multi-scale cell and tissue mechanics, including collagen deposition and remodeling, collagen-dependent cell migration and contractility, and tissue plastic deformation. Available human clinical data evaluating cavity contraction and histopathological data from an experimental porcine lumpectomy study were used for model calibration. The computational model was successfully fit to data by optimizing biochemical and mechanobiological parameters through Gaussian process surrogates. The calibrated model was then applied to define key mechanobiological parameters and relationships influencing healing and breast deformation outcomes. Variability in patient characteristics including cavity-to-breast volume percentage and breast composition were further evaluated to determine effects on cavity contraction and breast cosmetic outcomes, with simulation outcomes aligning well with previously reported human studies. The proposed model has the potential to assist surgeons and their patients in developing and discussing individualized treatment plans that lead to more satisfying post-surgical outcomes and improved quality of life.

Quality of life and satisfaction of patients after oncoplastic or traditional breast-conserving surgery using the BREAST-Q (BCT module): a prospective study

INTRODUCTION

The oncoplastic conservative surgery was developed as a natural evolution of traditional surgery, attempting to improve the therapeutic and aesthetic outcomes where tumor resection could be followed by not-adequate results. Our primary aim is to evaluate how patient satisfaction and quality-of-life after conservative oncoplastic surgery, using BREAST-Q (BCT Module), change pre- and post-operatively. The secondary aim is to compare patient-reported outcome after oncoplastic or traditional conservative surgery.

PATIENTS AND METHODS

We enrolled 647 patients who underwent traditional conservative surgery or oncoplastic surgery from January 2020 to December 2022. Only 232 women (35.9%) completed the BREAST-Q questionnaire on a web-based platform, at the preoperative phase and 3 months after treatment.

RESULTS

The average score of "Psychosocial well-being" and "Satisfaction with Breasts" 3 months after surgery showed a statistically significant improvement, while the average score for "Physical well-being: Chest" at 3 months showed a worsening compared to the baseline. "Sexual well-being" did not show statistically significant change. A significant difference between the post-operative outcome of oncoplastic surgery and traditional surgery was observed only for Physical well-being (better for traditional surgery).

CONCLUSIONS

The study showed significant improvement in patient-reported outcomes 3 months after the surgery, except for physical discomfort that increases especially after oncoplastic surgery. Furthermore, our data, as well as many others, point to the appropriateness of using OCS where there is an effective indication, while the perspective of patients cannot find significant superiority over TCS in any of the areas analyzed.

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.

Oncoplastic level II volume displacement surgery for breast cancer: oncological and aesthetic outcomes

Oncoplastic breast-conserving surgery (OBCS) is increasingly used to treat breast cancer with the dual purpose of performing a radical oncological resection while minimizing the risk of post-operative deformities. The aim of the study was to evaluate the patient outcomes after Level II OBCS as regards oncological safety and patient satisfaction. Between 2015 and 2020, a cohort of 109 women consecutively underwent treatment for breast cancer with bilateral oncoplastic breast-conserving volume displacement surgery; patient satisfaction was measured with BREAST-Q questionnaire. The 5-year overall survival and disease-free survival were 97% (95%CI 92, 100) and 94% (95%CI 90, 99), respectively. In two patients (1.8%), mastectomy was finally performed due to margin involvement. The median patient-reported score for "satisfaction with breast" (BREAST-Q) was 74/100. Factors associated with a lower aesthetic satisfaction index included: location of tumour in central quadrant (p = 0.007); triple negative breast cancer (p = 0.045), and re-intervention (p = 0.044). OBCS represents a valid option in terms of oncological outcomes for patients otherwise candidate to more extensive breast conserving surgery; the high satisfaction index also suggests a superiority in terms of aesthetic outcomes.

Aesthetic, Quality-of-Life, and Clinical Outcomes after Inferior Pedicle Oncoplastic Reduction Mammoplasty

BACKGROUND

Oncoplastic breast surgery is more likely to achieve superior aesthetic outcomes compared to lumpectomy alone. Oncoplastic reduction mammoplasty (ORM) is a volume displacement oncoplastic technique that combines lumpectomy and reduction mammoplasty. Data on aesthetic and quality-of-life (QoL) outcomes after ORM are scarce in the literature. Based on a literature review, this present study reports outcomes on the largest group of ORM patients to date.

METHODS

A retrospective review was conducted of all patients who underwent ORM between 2011 and 2018 at a tertiary care centre. Patients were excluded if no pedicle information was available or did not undergo post-operative radiotherapy. All patients with available post-operative photographs were aesthetically evaluated by four blinded, independent investigators blinded based on breast symmetry, nipple symmetry, and overall appearance. The BREAST-Q (breast conserving module) was used to assess QoL outcomes.

RESULTS

Two-hundred-and-sixteen consecutive patients (223 breasts) were included. Macromastia (cup size D or higher) was present in 173 patients (80.1%). Inferior pedicle ORM was utilized in 179 (80.3%) breasts. Eighty-eight patients (40.7%) were aesthetically evaluated, of whom 69 patients (78.4%) had "good", "very good", or "excellent" grades in all aesthetic categories. Seventy-five patients (85.2%) had "good" or better grades in overall appearance. Preoperative ptosis grade, cup size, presence of post-operative complications, and breast specimen weight had no significant correlations with aesthetic grades. Inferior pedicle ORM was associated with a higher "satisfaction with breast" Q-score (p=0.017) compared to other pedicle approaches.

CONCLUSION

Inferior pedicle ORM achieves objectively excellent aesthetic outcomes and high patient satisfaction with the reconstruction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

'Breast Cosmesis After Breast-Conserving Therapy' Who is the Judge, Patient or Surgeon?

INTRODUCTION

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts-this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient's perception.

METHOD

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen's kappa was calculated to define the strength of the inter-rater agreement.

RESULTS

One hundred twelve patients with a mean age of 59 (range 27-89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions 'How your lumpectomy breast looks?' and 'How you look in the mirror unclothed?' respectively (Cohen's k = 0.464, 95% CI 0.337-0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen's k = 0.172, 95% CI - 0.020-2.093, p = 0.067).

CONCLUSION

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

Predictive Factors of Satisfaction Following Breast Reconstruction: Do they Influence Patients?

INTRODUCTION

This study aims to analyze whether there is any patient- or treatment-related factor that can influence patients' body perception after mastectomy and autologous or implant-based breast reconstruction.

MATERIALS AND METHODS

This retrospective cohort study included patients who underwent immediate implant-based or DIEP flap breast reconstruction. Predictive factors analyzed included chemotherapy, radiotherapy, hormone therapy, body mass index, age, type of mastectomy, and follow-up length. The BREAST-Q was administered postoperatively almost 2 years from the last surgical procedure. Mean BREAST-Q scores were reported for the overall cohort and by modality for the postoperative period. A linear regression model was applied to all BREAST-Q scores with all predictor factors.

RESULTS

In total, 325 patients were enrolled in this study (133 DIEP flap and 192 implant-based reconstructions). The DIEP flap reconstruction group with a previous nipple sparing mastectomy showed the highest scores. Patients with a longer follow-up were less satisfied than the ones with a shorter follow-up, which could be considered as an assessment of the outcome. No significant difference was reported between patients who underwent radiotherapy, chemotherapy or hormone therapy and those who did not. Furthermore, age and BMI had no influence on patient satisfaction.

CONCLUSION

This study is the first that groups a large number of patients and analyzes predictive factors of long-term satisfaction of patients undergoing breast reconstruction. This can be regarded as a pilot study to raise the awareness of everyone's clinical practice to predict the attitude that patients have after surgery and to prepare them in the best possible way.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com .

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.

Long-Term Patient Satisfaction and Quality of Life After Breast-Conserving Therapy: A Prospective Study Using the BREAST-Q

Background

Poor patient-reported satisfaction after breast-conserving therapy (BCT) has been associated with impaired health-related quality of life (HRQOL) and subsequent depression in retrospective analysis. This prospective cohort study aimed to assess the HRQOL of patients who have undergone BCT using the BREAST-Q, and to identify clinical risk factors for lower patient satisfaction.

Methods

Patients with primary breast cancer undergoing BCT were asked to complete the BREAST-Q preoperatively (T1) for baseline evaluation, then 3 to 4 weeks postoperatively (T2), and finally 1 year after surgery (T3). Clinicopathologic data were extracted from the patients’ charts. Repeated measures analysis of variance (ANOVA) was used to determine significant differences in mean satisfaction and well-being levels among the test intervals. Multiple linear regression was used to evaluate risk factors for lower satisfaction.

Results

The study enrolled 250 patients. The lowest baseline BREAST-Q score was reported for “satisfaction with breast” (mean, 61 ± 19), but this increased postoperatively (mean, 66 ± 18) and was maintained at the 1 year follow-up evaluation (mean, 67 ± 21). “Physical well-being” decreased from T1 (mean, 82 ± 17) to T2 (mean, 28 ± 13) and did not recover much by T3 (mean, 33 ± 13), being the lowest BREAST-Q score postoperatively and in the 1-year follow-up evaluation. In multiple regression, baseline psychosocial well-being, body mass index (BMI), and type of incision were risk factors for lower “satisfaction with breasts.”

Conclusion

Both the aesthetic/surgery-related and psychological aspects are equally important with regard to “satisfaction with breasts” after BCT. The data could serve as the benchmark for future studies.

Outcomes in volume replacement and volume displacement techniques in oncoplastic breast conserving surgery: A systematic review

INTRODUCTION

Volume Replacement (VR-OBCS) and Volume Displacement Oncoplastic Breast Conserving Surgery (VD-OBCS) are commonly used in the management of breast cancer. Many studies summarize the individual postoperative outcomes of these two procedures; however, there is a lack of research that compares outcomes of these approaches. This review summarizes the available VR and VD-OBCS literature in terms of oncological, cosmetic, and clinical outcomes.

METHODS

An online literature search (MEDLINE, EMBASE, PubMed, and CINAHL) was performed. Studies were included if they were written in English, had more than 10 adult (18+) female patients who underwent VR-OBCS or VD-OBCS, and reported at least one well-described oncological, clinical, or cosmetic outcome RESULTS: Thirty-three studies (26 VR-OBCS and 7 VD-OBCS) were included in this review; VR-OBCS studies were separated based on the use of latissimus dorsi (LD) flaps. Studies utilizing VR-OBCS with LD flaps reported the highest rate of all oncological outcomes; VR-OBCS studies without LD flaps reported the lowest. Rates of hematoma, seroma, and wound dehiscence were highest in VR-OBCS with LD flaps; partial flap loss and fat necrosis were highest in VR-OBCS without LD flaps and infection was highest in VD-OBCS studies. Inconsistencies in methodology (cosmetic outcome measures, outcome definitions, and time horizons) were found in all procedural groups.

CONCLUSION

Differences in outcomes for both OBCS procedures may be due to the heterogeneity of patient populations. "Doers" and "Users" of breast oncoplastic research should consider tumor size, laterality of tumor, breast size, measurement scales, and defensible time horizons before the application of a study's conclusions.

Age and cancer treatment factors influence patient-reported outcomes following therapeutic mammoplasty and contralateral symmetrisation for the treatment of breast cancer

BACKGROUND

Oncoplastic surgery for breast cancer has increased in popularity over the last few years, with oncological safety confirmed in several studies. There are, however, limited published data on patient-reported outcomes from this surgical approach. This study assessed patient-reported outcomes of satisfaction following therapeutic mammoplasty and contralateral symmetrisation (TMCS) as part of breast cancer treatment in relation to other patient and treatment factors.

METHODS

The validated BREAST-Q™ breast reduction module was sent to all surviving patients who had no documented cancer recurrence and had undergone TMCS in NHS Tayside between August 2013 and August 2017. The Q-score was used to analyse data and correlate with patient clinical information, surgical, pathology and treatment factors. Ethical approval was granted by the University of Dundee ethics committee.

RESULTS

The patient response rate to the study was 64.5% (60 of 93 patients), with a mean age of 59 years (range 41-75 years). In all domains, patients reported high levels of satisfaction with outcomes. There were strong correlations between domains with the exception of physical symptoms. Younger patients reported poorer outcomes in domains that related to satisfaction with outcomes of surgery, psychosocial aspects, sexual function and physical symptoms. Treatment with chemotherapy and/or trastuzumab and lymph node positivity were associated with poorer outcomes in a number of domains.

CONCLUSIONS

Our results demonstrate that patients report high levels of satisfaction after TMCS, but this is influenced by age. Patient-reported outcomes that include physical and psychosocial appear to be more strongly influenced by medical treatments than surgery.

Breast-conserving therapy can be offered to women with prior breast augmentation

INTRODUCTION

Breast cancer in women with cosmetic breast implants is increasingly common. Over the past decade, there has been a push for mastectomy and reconstruction in these patients, based on a fear of poor aesthetic results from small breast volume, and radiation-induced capsular contracture. At the Paris Breast Centre, augmented women routinely undergo lumpectomy with whole-breast irradiation (BCT).

MATERIALS AND METHODS

A consecutive cohort of 50 augmented women, who had attempted BCT for early breast cancer at our institution between 2003 and 2018, were retrospectively identified. Post-treatment complications, oncologic outcomes, capsular contracture rates, long-term cosmetic outcomes, and patient-reported outcomes were evaluated.

RESULTS

The median follow-up was 51 months. Margins were involved in 7 women (14%); 4 of whom underwent successful re-excision, and 3 had a mastectomy, for an early mastectomy rate of 6%. There were no early complications, nor cases of early implant loss. Long-term aesthetic results were evaluated using our 5-point scale: An excellent (5), or good (4) result was obtained in 68%. Significant capsular contracture (Baker grade 3 or 4) developed in 34%, of which, 5 women underwent capsulotomy and fat grafting; 4 of 5 downstaging their Baker grade. The estimated 5-year local recurrence rate was 2.3%. Ninety-five percent of participants would recommend BCT to augmented women.

CONCLUSION

BCT is feasible and safe in augmented women with good long-term aesthetic results, and should be considered to avoid unnecessary mastectomy.

Does receipt of preference sensitive care impact patient reported outcomes following breast cancer surgery?

BACKGROUND

Patients with early breast cancer have multiple surgical options, with their choice being based on personal values, and ultimately being preference sensitive. Most patients will choose breast conserving surgery (BCS) as their preferred management, with some ultimately requiring mastectomy. These patients may have lower satisfaction with this approach than others choosing mastectomy as their preferred option.

METHODS

The BREAST-Q patient reported outcomes (PRO) measurement tool was retrospectively administered to patients undergoing mastectomy.

RESULTS

Patients choosing an index mastectomy had higher satisfaction with breasts score than those originally having BCS (58.0 vs 44.0; p = 0.012). Quality of life domains were also higher in those originally choosing a mastectomy, including: psychosocial (72.5 vs 63.0; p = 0.019), sexual (48.0 vs 36.0; p = 0.042), and physical well being of the chest domains (80.0 vs 72.0; p = 0.031).

CONCLUSION

Patients undergoing mastectomy after initial breast conserving surgery report lower PRO's than those initially choosing mastectomy. This suggests that patient preferences need to be considered when interpreting PRO's following breast cancer surgery.