Oncoplasty as the Standard of Care in Breast Cancer Surgery

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

There are three generations of surgeons in this oncoplastic era. The first were the pioneers who began to do these surgeries between 1980 and 1990, mostly European surgeons, after the oncological legitimacy of BCT was established in the 1980s. The next generation were breast surgeons who trained with some of the pioneers, or went to progressive plastic surgery departments to obtain specific training in plastic and reconstructive techniques. The third generation are the new breast surgeons who are receiving this training as part of their surgical curriculum, as in Brazil, or as a subspecialty of plastic surgery or general surgery, as is being carried out in the UK.

Between the second and third generations contains a group of surgeons who perform most of the breast cancer surgeries in the world. They do not have training in OPS and have had minimal opportunities to obtain such training. These surgeons are unable to offer breast reconstruction to most of their patients due to poor access to plastic surgeons willing to perform reconstructions. Many of these surgeons are now looking for training opportunities with short intensive courses in OPS to help them care for their patients. They are already specialised surgeons, with different degrees of experience and technical skills in breast surgery. How do we provide practical guidance for mentors to help these colleagues? What are the implications for mentoring? What are the limitations for these different courses? By who and how should the limits be set? These are the unsolved yet fundamental questions for breast surgery in the next few years.

The benefits of training a skilled surgeon competent in all oncological and aesthetic procedures of the breast has many obvious advantages. This skilled surgeon might have a background in plastic or breast surgery with the additional training making him or her a surgeon with both competencies. This paradigm has already taken hold in the UK with nine oncoplastic fellowships available to plastic and breast surgeons. Australia also has a number of these fellowships available. Brazil is training breast surgeons in oncoplasty and is beginning to set the standards that a mastologist (breast surgeon) must meet in order to qualify as a specialist in breast surgery. The European Union has some programmes leading to a certificate in OPS. The US has lagged the rest of the world in embracing this new specialty and in establishing programmes leading to proficiency in OPS. Despite scores of breast fellowships available to general surgeons leading to a specialisation in breast disease and cancer, with additional exposure to radiation and medical oncology, radiology, psychiatry, plastic surgery, genetics and nutrition, most fellowship trained US breast surgeons cannot perform basic mammoplasties or use glandular flaps for breast reshaping. They have even less competence with post-mastectomy reconstruction. Annual courses in oncoplastics by the American Society of Breast Surgeons and the American Society of Breast Disease are encouraging, but the utility of a weekend course in creating a new paradigm for breast surgery must be questioned. In the US, politics and turf battles may delay the creation of this new specialty but ultimately the public will demand what is in their best interest.

This fragmented approach in terms of breast cancer surgery, in times of such major advancements in the understanding of the molecular underpinnings of the disease and more sophisticated and efficacious plastic and reconstructive surgery options seems illogical and certainly interferes with the ultimate goal of translating these new technologies into improved quality of life for our patients. Breast reconstruction should be integral to breast cancer treatment for most patients, not an option. How do we mentor these new trainees and for how long? This will depend on the surgical background of the mentee, making it difficult to establish a standard norm. It is more subjective than other surgical disciplines or standard surgical residency training. The learning curve should be individualised for each technique and surgeon, because it does not represent a new specialty, but a surgical refinement of conservative and radical approaches in breast cancer surgery. Mentors should identify technical limits and establish boundaries for their mentees, using a model of levels of competence. Objective variables of technical skills should be based on competencybased training (see Table 2).27 A proposal of a curriculum for OPS is shown in Table 3, but there is a lack of a consensus as to which is the ideal one, and it will probably be individualised for different realities and needs.

This is an exciting time for OPS mentoring. New instruments, in addition to the classic ones currently used in theatres, should be created. One of them may be for performance assessment, which could be internetbased, simulating real cases with virtual reality, and another could be telementoring. In the end, OPS will have a profound effect on the way breast cancer surgery is practiced and mentored. The present is a critical period for establishing the framework for training and competence, and grooming future leaders to train the next generation of surgeons to advance the specialty forward. The success of this ambitious undertaking will critically depend on how to mentor this new generation of surgeons. Overall, mentoring must be individualised, ethically based, and committed to present and future patients, mentees and new potential areas for research.

Conclusions
Surgeons play an influential role in the care of the breast cancer patient. They are often the physicians who biopsy and diagnose the breast cancer patient and, if not, most often have the first discussions about therapy after the biopsy results are known. These conversations are not limited to cancer surgery, but often include dialogue about reconstructive surgery, chemotherapy and radiation therapy, and quality of life matters. This required expertise in additional areas is now taught (in a cursory format) in most breast fellowships in different countries. From a surgical perspective, the breast surgeon plays a key role. The decision to downsize a tumour with neoadjuvant chemotherapy requires an understanding of tumour biology, cancer surgery and aesthetic breast surgery. The discussion regarding BCT versus mastectomy requires a good understanding of the aesthetic quality of the breast that will be left behind after a partial mastectomy, versus possibly an improved result with mastectomy and reconstruction. The most challenging lumpectomies often require plastic surgery expertise. The potential quality of post-mastectomy reconstruction requires an understanding of which patients might be better served with tissue flaps versus expanders or definitive implants.

Finally, we believe that all breast surgery today should conceptually be ‘oncoplastic surgery’, where oncological principles and aesthetic considerations are both taken into account to obtain the optimal oncological and aesthetic outcome. This is an ideal that we should strive to obtain but, admittedly, will be difficult to accomplish. This will require a new training paradigm for the next generation of breast and plastic surgeons and the retraining of older surgeons. The logistics of this training will be complicated by ‘turf battles’ between plastic surgeons, general and breast surgeons. Questions regarding credentialling, training and medical legal matters will have to be addressed on international and national levels. None of these concerns has anything to do with the welfare of the patient. Regardless of these obstacles, however, this new expertise will result in a higher standard of care for all breast patients and will, undoubtedly, be something that patients will demand of their surgeons.

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