Oncoplasty as the Standard of Care in Breast Cancer Surgery

European Oncology & Haematology, 2014;10(1):43–7

Oncological and Aesthetic Results
OPS, now referring to simultaneous mammoplasty or breast reshaping and partial mastectomy in this review, is a technique that has been utilised throughout the world for more than 20 years. Its use has become more and more popular as a means to radically resect the tumour and leave the patient with an improved, if not excellent, aesthetic result. Over the past decade, the increased use of this methodology is demonstrated by the increasing number of original scientific articles published on oncoplasty, multiple new books and chapters written on this topic, the increased number of international breast meetings completely devoted to or with significant portions dedicated to OPS and, most importantly, formal training programmes resulting in competence in OPS.7

Despite this surge in interest and practice of OPS, there remains no prospective randomised clinical trials comparing this new approach with the standard BCT, and the quality of the reported studies seem to be less than ideal.8,9 In their review of 11 prospective oncoplastic studies, Haloua and colleagues9 demonstrated a 7–22 % positive margin rate in OPS compared with the 20–40 % accepted rate in standard BCT. This significant difference should result in a lower rate of re-excisions and better aesthetic outcomes. In fact, Haloua demonstrated good cosmetic outcomes in 84-89 % of patients, which is higher than typically reported in standard BCT.10 Importantly, they also demonstrated significantly higher scores for quality of life measures when comparing OPS and standard BCT. We summarise the results of the prospective studies11–22 in Table 1. A recent meta-analysis by Losken23 demonstrated larger resection volumes, increased satisfaction with aesthetics and decreased rates of positive margins, re-excisions and local recurrences for OPS, although follow-up was admittedly shorter term. No significant delay in adjuvant chemotherapy and radiotherapy has been documented despite the increased complexity of these surgeries and inherent higher risk of complications.24,25 Long-term survival has been demonstrated to be equivalent for the two surgical approaches thus far.26 The cosmetic outcomes of OPS have been demonstrated to be superior in a number of different studies, but the stability of these result and relevance of these findings to an improved quality of life is currently unclear. A valid concern over the OPS approach is the reliability of clips placed for the purposes of a radiation boost, although advances in intraoperative radiation therapy may make this less of a concern. Tissue rearrangement during oncoplasty might result in a larger, less exact boost during external beam radiation therapy possibly resulting in a poorer aesthetic outcome and decreased local control of disease.9

This begs the question why such an increasingly popular technique does not have level I evidence supporting its practice. There are several potential explanations for this lack of evidence. From an oncological perspective, it seems intuitive that resecting larger volumes of tissue with larger margins should be at least equivalent oncologically to standard BCT. Despite this rather intuitive point, it may still be of value to demonstrate a possible superior outcome using OPS with regards to local recurrence and rates of re-excision. In addition, randomising patients to OPS versus BCT would best be performed by surgeons familiar with both techniques. In most countries, standard BCT is performed most commonly by general surgeons or breast surgeons, and OPS is typically performed by a team of oncological and plastic surgeons, making a direct comparison difficult. It is also possible that skilled oncoplastic surgeons might find it unethical to randomise a patient with macromastia or gigantomastia, a large tumour to breast size ratio, an inferior pole or retroareolar tumour to a technique (standard BCT) that they deem to be obviously inferior to OPS. In addition, patients would most likely be reluctant to be randomised to standard BCT rather than the ‘new’ OPS that has received so much positive media attention. In addition to the difficulties mentioned above, a trial would have to take into consideration tumour location, size, patient comorbidities, degree of ptosis, glandular versus fatty content of the breast and many other variables. Ultimately, OPS is individualised to each patient and is a combination of science and art. The oncoplastic surgeon uses his or her expertise in oncology and aesthetics and balances these factors with patient motivations and preferences, tissue quality and breast size and shape, age, previous breast surgeries, comorbidities, tumour location and size to come up with a custom-made operation for each patient. This complex process cannot easily be studied in a well-controlled prospective randomised trial to give a simplified answer as to whether OPS is as good as, or better than, conventional surgery. There are certain patients whose individual circumstances may benefit more or less from an oncoplastic approach, like those with gigantomasty, large resections (more than 20 % of breast volume), tumours in central, superior, medial and inferior quadrants.

Mentoring and Training Perspectives and Barriers
Mentoring is the provision of personal and professional guidance. Surgical education and maturation as a competent practitioner is highly dependent on this basic process. The advent of OPS will require different methods of mentoring and requires new strategies in teaching and setting limits to the mentee and between specialties. Leaders in OPS have an important role in this time of change as there is growing international interest in this new expertise and the benefits it provides to women with breast cancer. Surprisingly, there is no consensus between the many breast societies and plastic surgery societies all over the world in how to establish training programs despite the rapidly increasing number of surgeons from both specialties who are now interested in learning these techniques.

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Keywords: Oncoplastic surgery, breast-conserving treatment, breast cancer, breast reconstruction