Professional Documents
Culture Documents
a
Nottingham Breast Institute, Nottingham City Hospital, Nottingham, NG5 1PB, United Kingdom
b
Department of Plastic Surgery, Nottingham City Hospital, Nottingham, NG5 1PB, United Kingdom
KEYWORDS Summary Background: Oncoplastic breast conserving surgery (OBCS) allows women who may
Breast otherwise have mastectomy and immediate reconstruction (MxIR) the choice to conserve their
reconstruction; breast yet avoid deformity. We compared the outcome of these options.
Breast surgery; Methods: Two cohorts meeting study criteria were identified from prospectively audited series
Oncoplastic breast of women undergoing OBCS or MxIR. After case matching for age, tumour size and date of sur-
surgery; gery, stratification by breast size and controlling for radiotherapy; body image scale (BIS)
Patient reported scores of psychosocial function and patient reported outcome measures (PROMs) for breast
outcome measures; appearance and return to function were analysed.
Quality of life Results: A total of 567 women (286 treated by OBCS and 281 by MxIR) fulfilled inclusion
criteria. Demographics were similar between the two unmatched cohorts, except for radio-
therapy, age and tumour size (all p < 0.001). Overall, BIS score (p Z 0.002), self-rated breast
appearance, return to work and function (all p < 0.001) significantly favoured OBCS. Case-
matched women with larger breasts treated by OBCS reported better BIS scores (mean 3.30
vs. 5.37, p Z 0.011) and self-rated breast appearance score (p < 0.001) than MxIR, whereas
no significant difference was observed for smaller breasts. BIS and appearance favoured OBCS,
regardless of whether radiotherapy would have been avoided if treated by MxIR.
*
Parts of this article have been presented at the following meetings/conferences: 1. 2nd Australasian Breast Congress, Auckland, New
Zealand: 7th July 2016. 2. Association of Breast Surgery Conference, Manchester, UK: 17th May 2016. 3. BC3 Breast Cancer Coordinated Care
Conference, Washington, US: 31st March 2016. 4. 33rd Annual Miami Breast Cancer Conference, Miami, US: 12th March 2016. 5. Oncoplastic
& Reconstructive Breast Surgery (ORBS) International Scientific Meeting, Nottingham, UK: 22nd September 2015.
* Corresponding author. Nottingham Breast Institute, Nottingham City Hospital, Nottingham, NG5 1PB, United Kingdom. Fax: þ44 0115 962
7707.
E-mail addresses: jennett.kelsall@nuh.nhs.uk, jennett_kelsall@hotmail.com (J.E. Kelsall).
http://dx.doi.org/10.1016/j.bjps.2017.05.009
1748-6815/ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
1378 J.E. Kelsall et al.
Conclusion: OBCS offers suitable women the option to avoid MxIR while providing faster recov-
ery. Better psychosocial and self-rated satisfaction with breast appearance is achieved for
OBCS in all groups, regardless of the need for radiotherapy, apart from those women with smal-
ler breasts for whom the results are comparable.
ª 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Else-
vier Ltd. All rights reserved.
Table 4 Demographics of case-matched patients e Larger breast group: Oncoplastic breast conserving surgery >100 g and
mastectomy with immediate reconstruction >400 g.
OBCS MxIR p
n Z 105 (%) n Z 105 (%)
Invasive carcinoma 88 (83.8) 89 (84.8)
DCIS 17 (16.2) 16 (15.2) p Z 1.0b
Age
Mean 52.5 yrs 53.6 yrs p Z 0.419a
Median 52 yrs 54 yrs
Tumour size (Invasive þ DCIS)
Mean 25.04 mm 25.95 mm p Z 0.545a
Median 24 mm 24 mm
Node positive 27 (31) 33 (31.7) p Z 1.0b
Adjuvant radiotherapy 99 (94.3) 34 (32.4) p Z <0.001b
Adjuvant hormone therapy 45 (42.9) 52 (49.5) p Z 0.406b
Adjuvant chemotherapy 42 (44.2) 44 (41.9) p Z 0.853b
Neoadjuvant chemotherapy 10 (9.5) 7 (6.7) p Z 0.613b
OBCS, oncoplastic breast conserving surgery; MxIR, Mastectomy and immediate reconstruction; DCIS, Ductal carcinoma in situ. LNs,
lymph nodes.
a
t-test.
b
Chi-squared test.
Oncoplastic Breast Conserving Surgery with Mastectomy and Immediate Breast Reconstruction 1381
Table 6 Demographics of case-matched patients e Small breast group: Oncoplastic breast conserving surgery <100 g and
mastectomy with immediate reconstruction <400 g.
OBCS < 100 g MxIR < 400 g p
n Z 88 (%) n Z 88 (%)
Invasive Carcinoma 75 (85.2) 74 (84.1) p Z 1.00b
DCIS 13 (14.8) 14 (15.9)
Age
Mean 51.93 51.36 p Z 0.695a
Median 52 49
Tumour size (Invasive þ DCIS)
Mean 22.51 21.49 p Z 0.522a
Median 20.5 19.5
Node positive 27 (34.2) 19 (21.6) p Z 0.100b
Adjuvant radiotherapy 83 (94.3) 21 (23.9) p < 0.001b
Adjuvant hormone therapy 53 (60.2) 43 (48.9) p Z 0.171b
Adjuvant chemotherapy 34 (42.5) 28 (31.8) p Z 0.203b
Neoadjuvant chemotherapy 8 (9.1) 2 (2.3) p Z 0.104b
OBCS, oncoplastic breast conserving surgery; MxIR, Mastectomy and immediate reconstruction; DCIS, Ductal carcinoma in situ. LNs,
lymph nodes.
a
t-test.
b
Chi-squared test.
faster across all measures for OBCS and was statistically (mean 3.59 vs. 4.69, t-test p Z 0.037) and better satis-
significant for return to work (mean 10.24 vs. 13.53 weeks, faction with the appearance of the breasts (mean 2.54 vs.
median 4 vs. 8.5 weeks; ManneWhitney p Z 0.023) and 3.11, t-test p < 0.001) (Figure 2). Return to function was
domestic activity (Table 7). statistically significant in being faster in the OBCS cohort
for domestic activity and full activity (mean 13.6 vs. 17.0
weeks, median 8 vs. 12 weeks, ManneWhitney p Z 0.004)
Radiotherapy (Table 8).
Patients in the OBCS cohort who would still have
Patients in the OBCS cohort who could have avoided post- required radiotherapy if treated by mastectomy (n Z 68)
mastectomy radiotherapy if treated by mastectomy were compared with those MxIR patients who did go on to
(n Z 218) were compared with the MxIR cohort who did not have post-mastectomy radiotherapy (n Z 81); the com-
require PMR (n Z 200) (Table 8); the comparison revealed parison revealed that the OBCS cohort fared significantly
that the OBCS cohort also fared better in terms of BIS better in terms of BIS (mean 4.85 vs. 7.26, t-test p Z 0.034)
Figure 1 Patient reported outcomes of satisfaction with appearance. Oncoplastic breast conserving surgery versus mastectomy
and immediate reconstruction. Matched cohorts: large and small breast groups.
1382 J.E. Kelsall et al.
Figure 2 Patient reported outcomes of satisfaction with appearance. Oncoplastic breast conserving surgery versus mastectomy
and immediate reconstruction. Comparison of patients not requiring post-mastectomy radiation with patients who would require
post-mastectomy radiation.
Table 9 Need for post mastectomy radiotherapy e PROMs that this group would be better served by OBCS.24 Our group
comparison: OBCS patients who WOULD have needed post previously reviewed the literature relating to elderly women
mastectomy radiotherapy; MxIR Patients who DID have and concluded that, although suitable for MxIR, OBCS often
adjuvant radiotherapy. offered a simpler alternative.25
OBCS also confers the benefit of earlier return to func-
OBCS MxIR p tion compared with MxIR as demonstrated by earlier re-
n Z 68 n Z 81 ported return to work, domestic activity and full activity in
Body image scale score:
our study. Clearly, there are many factors that influence
Mean 4.85 7.26 p Z 0.034a
this outcome, but an average (and median) 8-week shorter
Median 2 5
return to work was observed with OBCS, despite the addi-
Return to work (weeks)
tional requirement for post-operative radiotherapy in 91%
Mean 20.43 18.52 p Z 0.868b
of cases (c/w 28% after MxIR). Given that most OBCS op-
Median 14 12
erations are performed as day-cases and MxIR generally
Return to domestic activity (weeks)
require more prolonged hospital stays, the economic
Mean 4.30 6.39 p Z 0.06b
benefit of OBCS, although not assessed in this study, is
Median 3 4
likely to be significant.
Return to full activity (weeks)
With regard to the PROMs assessment in our study, the
Mean 18.43 23.28 P Z 0.246b
Hopwood BIS19 has been used at our institution for many
Median 8 12
years was validated in breast patients and predates the
Breast Q. Winters et al. noted a good psychometric profile
PROMS; Patient reported outcome measures; OBCS, oncoplastic and high levels of internal consistency with the BIS; how-
breast conserving surgery; MxIR, Mastectomy and immediate
ever, they did criticise the lack of a clear threshold for body
reconstruction.
a image disturbance,26 as did Korus et al..27 There have been
t-test.
b
ManneWhitney test. several systematic reviews of PROMs used in assessing pa-
tient satisfaction and quality of life after breast surgery.
Chen et al. confirmed that BIS was one of the more rigor-
ously developed tools; in addition, they confirmed that
being flat chested for a variable and often prolonged period while no PROMs tool currently addresses all surgery-specific
and then undergoing major and often challenging recon- and psychometric issues, BIS has demonstrated adequate
structive surgery. reliability, clinical validity, discriminant validity, sensitivity
Other patient groups that may particularly benefit from to change and consistency of scores between different
OBCS are women with a high BMI, comorbidities, the elderly, breast cancer treatment centres.20
and those who require axillary node dissection. A recent One criticism of our study may be that we have not re-
study by Tong et al. reported that the complication rate from ported the effect of time beyond 1 year on BIS, as breast
surgery was significantly less after OBCS for women with a satisfaction scores can change with time. Atisha et al.
high BMI or comorbidities.23 Similarly, Wang et al. reported a found that satisfaction with implant reconstruction and
high complication rate for MxIR with implants in women breast conserving surgery declined with time.28 However,
requiring full axillary node dissection, and it was postulated their study was a retrospective nationwide postal
1384 J.E. Kelsall et al.
questionnaire and thus subject to many biases. Crucially, it Appendix A. Supplementary data
did not differentiate between immediate and delayed
reconstruction or report on oncoplastic conservation pro- Supplementary data related to this article can be found at
cedures. Recently, a smaller retrospective cohort study http://dx.doi.org/10.1016/j.bjps.2017.05.009
reported that patients undergoing mastectomy and recon-
struction have at least as good quality of life and satisfac-
tion outcomes as breast conservation.17 However, again, References
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