Oncoplastic to Onco-Aesthetic Surgery: A Movement toward Overtreatment?

Article information

Arch Plast Surg. 2017;44(1):85-86
Publication date (electronic) : 2017 January 20
doi : https://doi.org/10.5999/aps.2017.44.1.85
Breast Surgical Oncology, MammoCare, Singapore.
Correspondence: Mona P Tan. Breast Surgical Oncology, MammoCare, Singapore, 38 Irrawaddy Road, #06-21, Singapore 329563, Republic of Singapore. Tel: +65-6694-1706, Fax: +65-6694-1746, jabezhopems@gmail.com
Received 2016 May 22; Revised 2016 July 12; Accepted 2016 July 12.

Dear Editor:

I read with considerable concern the communication from Dr Carmichael and Dr Mokbel in this journal on the subject ‘Evolving Trends in Breast Surgery: Oncoplastic to Onco-Aesthetic Surgery’ [1]. The authors laud the use of oncoplastic breast surgery (OBS) and characterise its further development as deserving of the designation ‘onco-aesthetics’. This suggests a sense of justification for giving a pre-eminent role to aesthetic procedures in the surgical treatment of breast cancer. Such a prioritisation calls for serious reconsideration in light of treatment objectives, as current evidence indicates that the use of OBS may have a negative impact on patient outcomes in terms of survival and morbidity.

Current data demonstrate that breast conservation treatment (BCT) is associated with higher breast cancer-specific survival and improved local control compared with mastectomy [23]. This fact legitimises the goal of expanding the eligibility for BCT and extending its utility. The quality of cosmetic outcomes is also a factor to be considered, and there is little objection to using reasonable methods to achieve acceptable breast forms. However, the incremental and progressive use of OBS for the express purpose of achieving aesthetic excellence is controversial. There are data to suggest that patients who have undergone OBS score significantly worse than those who have undergone standard BCT in terms of cosmetic outcomes, when assessed objectively by the software programme BCCT.core [4]. This indicates that significant mobilisation during mammoplasty has implications for both cosmesis and effective boost delivery during radiotherapy. Since conventional surgery was also found to offer superior outcomes with respect to quality of life and function, it has been concluded that, on the whole, the use of OBS might be disadvantageous [4]. Apart from a failure to demonstrate unequivocal improvement in cosmetic outcomes, OBS techniques are also more complex and may result in higher rates of complications; moreover, they have not been shown to provide significant improvement in local control [5]. The data indicate that larger margins with OBS may not translate to improved local control, but may create the need for additional procedures like mammoplasty, contralateral symmetrisation, and volume replacement with flaps [5]. A reductionist approach to BCT, antithetic to the philosophy that informs OBS, involves neoadjuvant systemic treatment where appropriate and demands accuracy in dissection for lower tissue resection volumes, which could decrease the need for excessively wide excisions and contralateral symmetrisations without compromising cosmesis and local control.

The adaptation of plastic surgery techniques to BCT has undoubtedly led to improvements in cosmetic outcomes. This has provided the impetus for ongoing development, resulting in an exponential increase in the range of OBS techniques. However, the routine and incremental use of OBS techniques is expansive and involves invasive procedures to a greater degree. This may be contrary to the basic tenets of medical therapy, which is founded on the principle of non-maleficence. Perhaps it is time to re-examine our objectives for the surgical treatment of breast cancer, and whether the current trend of oncoplastic to onco-aesthetic surgery stands up to the scrutiny of primum non nocere. In over-emphasising aesthetics in breast surgical oncology, we may be subjecting our patients to the disservice of overtreatment.

Notes

No potential conflict of interest relevant to this article was reported.

References

1. Carmichael AR, Mokbel K. Evolving trends in breast surgery: oncoplastic to onco-aesthetic surgery. Arch Plast Surg 2016;43:222–223. 27018587.
2. Hartmann-Johnsen OJ, Karesen R, Schlichting E, et al. Survival is better after breast conserving therapy than mastectomy for early stage breast cancer: a registry-based follow-up study of norwegian women primary operated between 1998 and 2008. Ann Surg Oncol 2015;22:3836–3845. 25743325.
3. van der Heiden-van der Loo M, Siesling S, Wouters MW, et al. The value of ipsilateral breast tumor recurrence as a quality indicator: hospital variation in the Netherlands. Ann Surg Oncol 2015;22(Suppl 3):S522–S528. 25986872.
4. Lansu JT, Essers M, Voogd AC, et al. The influence of simultaneous integrated boost, hypofractionation and oncoplastic surgery on cosmetic outcome and PROMs after breast conserving therapy. Eur J Surg Oncol 2015;41:1411–1416. 26260375.
5. De Lorenzi F, Hubner G, Rotmensz N, et al. Oncological results of oncoplastic breast-conserving surgery: long term follow-up of a large series at a single institution: A matched-cohort analysis. Eur J Surg Oncol 2016;42:71–77. 26382101.

Article information Continued