Journal of Plastic, Reconstructive & Aesthetic Surgery (2017) 70, 1377e1385

Comparing oncoplastic breast conserving

surgery with mastectomy and immediate
breast reconstruction: Case-matched patient
reported outcomes*
Jennett E. Kelsall a,*, Stephen J. McCulley b, Lisa Brock a,
Malin T.E. Akerlund a, R. Douglas Macmillan a

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

Received 18 November 2016; accepted 9 May 2017

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
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.
Introduction
Breast conserving surgery is the standard of care for small
breast carcinomas, achieving a good oncological and
aesthetic outcome in a very high percentage of cases. In
the present study, there is no indication to recommend
mastectomy, although it remains an informed choice. In
contrast, mastectomy is the standard of care for large and
locally advanced cancers. Between these extremes, the
effective oncological treatment of the index cancer could
be equally well served by breast conserving surgery or
mastectomy, although other competing risks and benefits
strongly influence surgeon and patient choice.
Oncoplastic breast conserving surgery (OBCS) expands
the indications for breast conserving surgery by allowing
proportionally larger excisions while maintaining breast
form.1 Its principle indication is in women whose cancer is
neither small enough to be treated by simple techniques
nor large enough to dictate mastectomy. It competes with
mastectomy and immediate breast reconstruction as an
informed choice in those women who wish to avoid a simple
mastectomy and replaces simple techniques of breast
conserving surgery that leave deformity. The concept and
indications sit well with the increased use of neo-adjuvant
therapy to downsize cancers traditionally managed by
mastectomy. That OBCS is a safe option for women with
cancers that have traditionally required mastectomy is
borne out in the recent literature. In a matched cohort
study, no significant difference was observed between
OBCS and mastectomy for T2 cancers in terms of overall or
disease-free survival.2
With improved adjuvant treatment and greater long
term survival, patient preference and quality-of-life factors
increasingly contribute to treatment choices.3 Despite the
development of OBCS, a recent trend towards women
choosing mastectomy instead of breast conserving surgery
has been identified in some countries, which is thought to
reflect a shift towards patients choosing prophylactic pro-
cedures in addition to their cancer surgery.4 Although this
may be due to a desire for symmetry offered by bilateral
reconstruction, it may also reflect an under-appreciation of
the consequences of this additional surgery or a lack of
informed choice.
Although there are numerous articles reporting the
quality-of-life and aesthetic outcomes of both simple
breast conserving surgery or mastectomy, with or without
total reconstruction (immediate and/or delayed),5e18 there
is little evidence in the literature directly comparing OBCS
with mastectomy and immediate reconstruction (MxIR).
This study aimed to compare the outcomes of these surgical
J.E. Kelsall et al.
options in terms of patient reported outcome measures
(PROMs).
Patients and methods
Prospectively collected audit data of surgery performed by
the two senior authors at the Nottingham City Hospital
Breast Institute were analysed. This consisted of over 700
and 500 cases of OBCS and MxIR, respectively, performed
between 1999 and 2014.
The initial entry criterion for cases to be included in this
report was the availability of PROMs data. This was routinely
collected at 1-year post treatment by postal questionnaire
and consisted of the Hopwood BIS19 assessment of psycho-
social function (Table 1) and institution-specific questions
regarding patient satisfaction with aesthetic outcome and
return to function (Table 2). The Hopwood BIS scores have
been collected for many years at the Nottingham Breast
Institute and are a validated PROMs tool.20 The mean BIS
score was calculated and used for analysis, with a lower
score indicating a better psychosocial outcome. For our
institution-specific questions, a lower score also indicates a
better patient reported outcome. Other inclusion criteria
were as follows: indication for surgery was either primary
invasive breast cancer or ductal carcinoma in situ (DCIS);
and surgery was either OBCS (requiring therapeutic mam-
maplasty [TM] or volume replacement with a local chest
wall perforator flap); or mastectomy with immediate
reconstruction. Exclusion criteria were as follows: surgery
for prophylactic or benign disease; previous breast radio-
therapy or previous treatment for breast cancer; delayed
reconstruction; and unavailability of PROMS data.
Initially, the two cohorts were compared unmatched to
observe whether there were any significant differences in
the demographics between them. The cohorts were then
case-matched for the following factors: age (within
5 years at the time of surgery); maximum size of tumour,
including DCIS surrounding an invasive cancer (within
10 mm); and date of reconstruction (within 3 years). The
cohorts were then controlled for breast size by stratifying
according to resection volumes. This was performed ac-
cording to the following algorithm: women with larger
breasts tend to be offered bilateral therapeutic reduction
mammaplasty as the method of OBCS, which often includes
a significant breast volume reduction. However, if treated
by MxIR, they were usually most suitable for autologous
breast reconstruction. Women with smaller breasts under-
going OBCS tend to be offered a breast mastopexy with the
only volume reduction being the wide local excision or they
Oncoplastic Breast Conserving Surgery with Mastectomy and Immediate Breast Reconstruction
Table 1 Hopwood Body Image Scale.a
Have you been feeling self-conscious about your appearance?
Have you felt less physically attractive as a result of your disease
or treatment?
Have you been dissatisfied with your appearance when dressed?
Have you been feeling less feminine as a result of your disease or treatment?
Do you find it difficult to look at yourself naked?
Have you been feeling less sexually attractive as a result of your disease
or treatment?
Did you avoid people because of the way you felt about your appearance?
Have you been feeling the treatment has left your body less whole?
Have you felt dissatisfied with your body?
Have you been dissatisfied with the appearance of your scar?
a
Hopwood P, Fletcher I, Lee A et al. A body image scale for use with cancer patients. European Journal of Cancer. 2001; 37: p196.
Re-printed with permission.
Table 2 Institution-specific patient reported outcome
measures.
Patient Questionnaire
1 What do you think of the appearance of your breasts
compared to before surgery?
Much better . Better . Same . Worse . Much
Worse
2 How long did it take you to get back to domestic activity?
. (weeks)
3 How long did it take you to get back to your job (if
applicable)? . (weeks)
4 How long did it take you to get back to full exercise/ac-
tivity? . (weeks)
are offered volume replacement with a local perforator
flap. If treated by MxIR, they are usually most suitable for an
implant reconstruction. The cohorts of women were there-
fore split into a ‘larger breast’ and ‘smaller breast’ groups
by using the following criteria: the ‘larger breast’ group had
total specimen weights >100 g if treated by OBCS (wide local
excision þ reduction tissue) or a mastectomy weight >400 g
if treated by MxIR; the ‘smaller breast’ group had a total
specimen weight of <100 g or a mastectomy weight <400 g.
To facilitate a comparison controlling for radiotherapy,
those in the OBCS cohort who would still have required
post-mastectomy radiotherapy (PMR) had they chosen this
option, were compared to those in the MxIR cohort who
did have post-mastectomy radiotherapy. Conversely, OBCS
patients who would not have needed post-mastectomy
radiotherapy had they chosen MxIR, were compared with
those in the MxIR cohort who did not require adjuvant
radiotherapy. Indications for radiotherapy were determined
using oncological data and local protocol for the era of this
study (more than 50 mm invasive size; four or more lymph
nodes involved or two or more factors present out of grade
III, lymphovascular invasion and positive lymph nodes).
Patient demographics, oncological characteristics and
adjuvant therapy received were compared between the
two cohorts. PROMs data were then compared between the
cohorts, initially unmatched and then followed by case
1379
Not a lot A little Quite a bit Very much
matching and stratification based upon breast size and
finally controlling for the need for radiotherapy. Chi-square
tests were used for categorical variables, and t-tests were
used to compare continuous variables. The ManneWhitney
U test was used to compare the medians of continuous
variables. All tests were two sided. A value of p < 0.05 was
considered significant. Statistical analysis was performed
using the Statistical Package for the Social Sciences version
17.0 (SPSS, Inc., Chicago, Ill.).
Our prospectively collected audit database was granted
local ethics board’s approval at its commencement. The
STROBE guidelines were adhered to in preparation of this
manuscript.
Results
A total of 286 and 281 women who had undergone OBCS and
MxIR, respectively, fulfilled inclusion criteria. In the OBCS
cohort, 204 and 82 women had undergone bilateral thera-
peutic mammaplasty and a chest wall perforator flaps
(LICAP [lateral intercostal artery perforator], LTAP [lateral
thoracic artery perforator], or TDAP [thoracodorsal artery
perforator]), respectively. In the MxIR cohort, 65, 105 and
111 women had undergone deep inferior epigastric perfo-
rator flaps, an latissimus dorsi  implant and an implant
reconstruction, respectively.
Unmatched comparison
An initial unmatched comparison of the demographics be-
tween the OBCS and MxIR cohorts demonstrated that they
were broadly similar, with the significant differences being;
mean age (54.9 years vs. 51.8 years, p < 0.001), total
tumour size (24.5 mm vs. 33.5 mm, p < 0.001) and radio-
therapy (91.3% vs. 28.8%, p < 0.001).
A comparison of the PROMs between the unmatched
cohorts showed a more favourable body image scale (BIS)
score for the OBCS cohort (mean 3.89 vs. 5.43, t-test
p Z 0.002), a faster return to work (mean 6.29 vs. 14.8
weeks, median 4 vs. 12 weeks, ManneWhitney test
p < 0.001) and full function (mean 14.73 vs. 18.83 weeks,
1380 J.E. Kelsall et al.

median 8 vs. 12 weeks, ManneWhitney test p Z 0.001)

Table 5 Case-matched large breast group PROMs com-
compared to the MxIR cohort (Table 3). Women having OBCS
parison: Oncoplastic breast conserving surgery >100 g and
also reported more favourable self-rated breast appear-
mastectomy with immediate reconstruction >400 g.
ance scores (mean 2.57 vs. 3.16; t-test, p < 0.001).
OBCS>100 g MxIR >400 g p
Case-matched comparison n Z 105 n Z 105
Body image scale score:
Analysing case-matched cohorts, the only significantly Mean 3.30 5.37 p Z 0.011a
different variable between both groups remained adjuvant Median 1 3
radiotherapy (p < 0.001, Tables 4 and 6). With stratification Return to work (weeks)
into ‘Large’ and ‘Small’ breast groups, for the ‘Large Mean 19.89 16.37 p Z 0.634b
Median 16 12
Return to domestic activity (weeks)
Table 3 Unmatched cohorts PROMs comparison: Onco- Mean 6.07 6.37 p Z 0.031b
plastic breast conserving surgery versus Mastectomy with Median 3 4
immediate reconstruction. Return to full activity (weeks)
Mean 15.37 19.58 p Z 0.008b
OBCS MxIR p
Median 8 12
n Z 286 n Z 281
PROMS; Patient reported outcome measures; OBCS, oncoplastic
Body image scale score: breast conserving surgery; MxIR, Mastectomy and immediate
Mean 3.89 5.43 p Z 0.002a reconstruction.
a
Median 1 3 t-test.
b
Return to work (weeks) ManneWhitney test.
Mean 6.29 14.85 p < 0.001b
Median 4 12
Return to domestic activity (weeks) Breast’ group, the OBCS cohort reported significantly better
Mean 5.21 6.03 p Z 0.002b BIS scores (mean 3.30 vs. 5.37, t-test p Z 0.011) (Table 5)
Median 3 4 and better rating of breast appearance (mean 2.18 vs. 3.21,
Return to full activity (weeks) t-test p < 0.001) than MxIR (Figure 1). Return to work for
Mean 14.73 18.83 p Z 0.001b the OBCS cohort was significantly faster for both domestic
Median 8 12 activity and full activity (mean 15.37 vs. 19.58 weeks,
PROMS; Patient reported outcome measures; OBCS, oncoplastic median 8 vs. 12 weeks, ManneWhitney p Z 0.008) (Table
breast conserving surgery; MxIR, Mastectomy and immediate 5). For the ‘Small Breast’ group, BIS scores (mean 5.69 vs.
reconstruction. 5.34, t-test p Z 0.715) (Table 7) and rating of breast
a
t-test. appearance were not significantly different (mean 3.22 vs.
b
ManneWhitney test. 3.11, t-test p Z 0.480) (Figure 1). Return to function was

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
significant for return to work (mean 10.24 vs. 13.53 weeks,
median 4 vs. 8.5 weeks; ManneWhitney p Z 0.023) and
domestic activity (Table 7).
Radiotherapy
Patients in the OBCS cohort who could have avoided post-
mastectomy radiotherapy if treated by mastectomy
(n Z 218) were compared with the MxIR cohort who did not
require PMR (n Z 200) (Table 8); the comparison revealed
that the OBCS cohort also fared better in terms of BIS
(mean 3.59 vs. 4.69, t-test p Z 0.037) and better satis-
faction with the appearance of the breasts (mean 2.54 vs.
3.11, t-test p < 0.001) (Figure 2). Return to function was
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)
(Table 8).
Patients in the OBCS cohort who would still have
required radiotherapy if treated by mastectomy (n Z 68)
were compared with those MxIR patients who did go on to
have post-mastectomy radiotherapy (n Z 81); the com-
parison revealed that the OBCS cohort fared significantly
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.

surgical options in a large cohort. Overall, it shows that in

Table 7 Case-matched small breast group PROMs com-
terms of psychosocial outcome as evaluated by BIS, and
parison: Oncoplastic breast conserving surgery <100 g and
self-rated breast appearance, OBCS generally fares signifi-
mastectomy with immediate reconstruction <400 g.
cantly better than MxIR. This difference is most marked for
OBCS < 100 g MxIR < 400 g p women with large breasts and those who would have had
n Z 88 n Z 88 radiotherapy with either surgical option. We also found
OBCS to be associated with a faster return to work and
Body image scale score:
function. These results are not surprising.
Mean 5.69 5.34 p Z 0.715a
For women with large breasts, OBCS offers the option of
Median 4 3
breast reduction, a procedure well recognised to confer
Return to work (weeks)
quality-of-life benefit in appropriate cases. This is borne
Mean 10.24 13.53 p Z 0.023b
out in other studies, with Hart et al. demonstrating that
Median 4 8.5
while overall body image satisfaction was maintained in
Return to domestic activity (weeks)
their MxIR cohort, patients undergoing OBCS with a thera-
Mean 4.73 5.85 p Z 0.025b
peutic reduction mammaplasty demonstrated a greater
Median 2 3.5
improvement in body image satisfaction and maintenance
Return to full activity (weeks)
of sexual function.21 Conversely, MxIR in such cases usually
Mean 15.61 19.91 p Z 0.93b
involves major surgery and while breast size can also be
Median 10 8
reduced and donor sites for autologous reconstruction may
PROMS; Patient reported outcome measures; OBCS, oncoplastic be enhanced in some cases, the nipple is usually sacrificed,
breast conserving surgery; MxIR, Mastectomy and immediate sensation is lost and recovery time is longer.
reconstruction. In contrast, women with smaller breasts are unlikely to
a
t-test.
b achieve a better breast aesthetic with OBCS; the best result
ManneWhitney test.
achievable for most being the maintenance of breast form.
Such cases may be suitable for overall enlargement with
(Table 9) and better satisfaction with the appearance of mastectomy and implant-based reconstruction if this is
their breasts (mean 2.66 vs. 3.28, t-test p Z 0.001) perceived to be desirable. The current study showed equity
(Figure 2). Differences in return to function did not reach of PROMs outcomes between OBCS and MxIR for women
significance between the two cohorts. with small breasts.
That breast aesthetics can be improved with both OBCS
and MxIR was specifically investigated in our study with the
Discussion question, “What do you think of the appearance of your
breasts compared with before surgery.” Usually in PROMs
Despite several studies reporting PROMs for OBCS or mas- related to breast appearance, the top rated outcome is
tectomy and immediate reconstruction separately, this limited to a woman reporting that her breasts are un-
study is one of the first to directly compare these two changed compared to before surgery. However, recognising
that breast cancer surgery can simultaneously both remove
the cancer and maintain or even enhance breast aesthetics
Table 8 Need for post mastectomy radiotherapy e PROMs
is fundamental to oncoplastic surgery, whether it be breast
comparison: OBCS patients who would NOT have needed
conservation or total reconstruction. Any quality-of-life
post mastectomy radiotherapy; MxIR patients who did NOT
improvement that can be reasonably offered to women
have adjuvant radiotherapy.
suffering so many insults is surely worthwhile. In the cur-
OBCS MxIR p rent study, 40e45% of women had chemotherapy with its
n Z 218 n Z 200 attendant side effects, while approximately 50% of women
had hormone therapy.
Body image scale score:
Radiotherapy is well recognised to adversely affect im-
Mean 3.59 4.69 p Z 0.037a
mediate breast reconstruction, whereas it is generally
Median 1 3
better tolerated by the intact breast. This is a further
Return to work (weeks)
reason why OBCS achieves significantly better PROMs than
Mean 3.85 13.55 p Z 0.252b
MxIR in such cases, and it should, therefore, in our opinion,
Median 8.5 12
be considered the preferred option in this scenario where
Return to domestic activity (weeks)
feasible. This recommendation has also been made by
Mean 5.50 5.89 p Z 0.012b
Peled et al. who reported significantly lower complication
Median 3 4
rates with OBCS utilising a therapeutic mammaplasty
Return to full activity (weeks)
technique as an alternative option to MxIR, in the setting of
Mean 13.6 17.0 p Z 0.004b
requiring post-operative radiotherapy.22 For many women
Median 8 12
where PMR is likely to be required, the alternative option to
PROMS; Patient reported outcome measures; OBCS, oncoplastic OBCS that is often given to them is simple mastectomy and
breast conserving surgery; MxIR, Mastectomy and immediate delayed autologous breast reconstruction, a major opera-
reconstruction. tion that may not occur for many months or years after the
a
t-test.
b original cancer surgery. Delayed reconstruction is recog-
ManneWhitney test.
nised to result in good PROMs, although the price paid is
Oncoplastic Breast Conserving Surgery with Mastectomy and Immediate Breast Reconstruction 1383

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
questionnaire and thus subject to many biases. Crucially, it
did not differentiate between immediate and delayed
reconstruction or report on oncoplastic conservation pro-
cedures. Recently, a smaller retrospective cohort study
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,
this study was not evaluating OBCS and did not discriminate
between immediate and delayed reconstructions in their
analyses, although of note immediate reconstruction made
up only 13.7% of their reconstructed patient group.
This highlights some of the difficulties interpreting the
literature on this subject, as studies have tended to
compare quite heterogeneous patient groups, often
without clearly differentiating between simple or onco-
plastic surgical techniques or the timing of reconstruction,
all of which is likely to significantly impact on patient re-
ported outcomes. Some previous studies have included
small numbers of patients undergoing OBCS within their
breast conservation cohort; however, these groups have not
been analysed separately, and so comparison with their
results is not easily possible.29 Where appropriately indi-
cated, however, OBCS has been shown to offer better pa-
tient outcomes compared with simple breast conservation
alone. Veiga et al. demonstrated in a prospective study
matched for age, BMI, and demographic and oncologic pa-
rameters that OBCS utilising local flaps or reduction tech-
niques demonstrated superior 12-month post-operative
quality-of-life outcomes compared with patients undergo-
ing simple breast conservation alone, with significantly
better physical and social functioning, emotional and
mental health as well as self-esteem.30
Another criticism of our study may be the arbitrary cut-
offs for breast size (400 g) and specimen weight (100 g). The
main purpose of these cut-offs is to distinguish broadly
between women who are more likely to have implant-based
or autologous breast reconstruction if treated by mastec-
tomy and those more likely to have volume replacement as
opposed to therapeutic mammaplasty if treated by OBCS.
Although the exact cut-offs may be debated for various
reasons, the principle of analysing by breast and specimen
size is important when assessing the relative merits of
oncoplastic surgery versus mastectomy and reconstruction
as breast size in an important indicator of the very different
options a woman has, particularly for OBCS.
In conclusion, our study has shown that OBCS offers
selected patients the option to avoid mastectomy, while
providing similar if not better psychosocial and self-rated
satisfaction with breast appearance, and faster return to
work and function, regardless of the need for radiotherapy.
The options offered to women with breast cancer who wish
to avoid a simple mastectomy should be re-evaluated on
the basis of this study and the other studies referenced.
Funding
This work received no external funding.
Conflict of interest
The authors declare no conflict of interest.
J.E. Kelsall et al.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.bjps.2017.05.009
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