Breast Surgeons and Oncoplastic Surgery

Breast surgeons utilizing oncoplastic techniques is commonplace in the United Kingdom, Europe, and parts of South America. In Canada and the United States, the adoption of oncoplastic surgery by breast surgeons has been slow to advance. Many factors play a role in the slow adoption, but education and training are most likely the greatest obstacles breast surgeons face. Breast surgery has evolved into its own specialty, and breast surgeons have widened their scope of practice to embrace and integrate aspects of other specialties to better care for the cancer patient. Oncoplastic techniques should be an essential addition to that scope of practice.

The treatment of breast cancer is a rapidly changing and dynamic field. The breast surgeon is the “first responder” to the crisis of a woman with a new breast cancer diagnosis. The breast surgeon explains the disease to the patient and partners with her to develop the best treatment plan based on multiple variables. Each woman has unique physical, biological, and emotional variables that must be factored into that plan. The patient with breast cancer has the best results when her care involves a multidisciplinary approach with all specialties involved in her treatment. As first responder, the breast surgeon has knowledge of the basic aspects of the specialties involved and navigates the patient to the other specialists when their expertise is required. In an effort to expedite the patient’s care, the breast surgeon has adopted aspects of radiology, genetics, and integrative medicine into their practice.

A newly diagnosed breast cancer patient will likely undergo multiple tests both before and after her diagnosis. Breast surgeons read mammograms daily and perform ultrasounds both in the clinic and in the operating room to better facilitate the treatment of their patient. Advanced breast imaging such as 3D mammography, magnetic resonance imaging, and ultrasound have improved the evaluation and diagnosis of breast cancer. Innovations such as contrast enhanced digital mammography and automated breast ultrasound are being recognized as new tools in advanced imaging. It is the breast surgeon who determines which tests are needed to obtain the best information regarding treatments. Many breast surgeons are certified to perform ultrasound and stereotactic core biopsies in the diagnosis of breast disease. Breast surgeons and radiologists work together to bridge specialties to facilitate the evaluation and surveillance of the woman with breast cancer.

With the new diagnosis comes the question of “why me?” Understanding and identifying risk factors for the occurrence of an initial or second breast cancer have also advanced significantly. There has been an explosion of information regarding genetic defects that increase a woman’s lifetime risk from 25–80%. The understanding of genetics is crucial in the ability to counsel the patient as to her options for treatment. Breast surgeons have adopted this knowledge into their practice and have been recognized as appropriate providers to counsel patients in genetics and genetic testing and share these responsibilities with geneticists when they are available.

When a woman is diagnosed, one of her first reactions is to have surgery yesterday . However, tumor biology of a woman’s breast cancer is often the driver of the order in which she will be treated. Biologically aggressive tumors such as estrogen and progesterone negative, HER-2 neu positive (Luminal B), and triple negative tumors are now recommended for treatment with neoadjuvant chemotherapy. With genomic sequencing, determining the precise treatment for each individual cancer is evolving. The ability to effectively downstage tumors gives women with later stage breast cancers more options in their surgical treatment. Now, more than ever, the breast surgeon must be aware of the nuances of tumor biology and identify the patient who needs referral to medical oncology. The breast surgeon must also impress upon the patient who is so anxious to have surgery first, the importance of neoadjuvant chemotherapy, when appropriate, to her total care.

Radiation therapy after partial mastectomy is an important component of breast conservation therapy. With the acceptance of varying modalities and time courses of radiation therapy, a 6-week course of daily whole breast radiation is being replaced by shortened whole breast radiation courses or better partial breast radiation options. Today a woman can potentially have her breast cancer surgery and her entire radiation therapy dose performed together in 1 day, with many other options offering shortened courses of radiation from 2–21 days. The breast surgeon evaluates the patient for the possible options of partial breast or whole breast radiation and works closely with the radiation oncologist to determine patient selection and the intraoperative placement of the radiation delivery system, as appropriate.

After the acute crisis of a breast cancer diagnosis and treatment, the patient begins the process of putting her life back together and understanding her “new normal.” The breast surgeon again is a part of this process. Many breast surgeons participate in monitoring the patient between 2–5 years after her cancer diagnosis. In the United States, most women are diagnosed with early stage disease. These women will have 98% survival. Survivorship becomes an important part of the treatment plan for every woman with breast cancer. Breast surgeons determine appropriate imaging needed for each patient in surveillance. They counsel women on lifestyle changes such as diet and exercise that are known to affect recurrence rates. They are knowledgeable in survivorship options from integrative medicine to psychological counseling, and refer the patient to these services to help the survivor thrive in her posttreatment life.

As a vital participant of so many advances in the multidisciplinary aspects of breast cancer, one would expect the breast surgeon to also be adept in the use of the multiple surgical options available today when a woman desires breast conservation. Sadly, this does not appear to be the case. If oncoplastic surgery has gained wide acceptance in Europe, the United Kingdom, and parts of South America, why are breast surgeons in the United States and Canada significantly behind in adopting these techniques?

A common model for oncoplastic repair in the United States and Canada is the two-surgeon approach. The breast surgeon removes the breast cancer and the plastic surgeon reconstructs the breast defect. One survey investigated current practices and polled members of both the American Society of Plastic Surgeons (ASPS) and the American Society of Breast Surgeons (ASBrS). This survey reported 50% of plastic surgeons believed they were not involved in reconstruction after partial mastectomy because breast surgeons did not refer patients to the plastic surgeon. Another survey polling ASBrS members showed 63% of breast surgeons refer patients to a plastic surgeon for a breast reduction with their cancer surgery when a reduction would be indicated. Only half of the breast surgeons surveyed routinely discuss oncoplastic procedures during the initial breast cancer surgical consultation, whereas 29% sometimes do and 20% never discuss such procedures. From the patient perspective, a recent Canadian report surveying women with breast conservation regarding their options for reconstruction indicated only 1.6% were referred to plastic surgery before surgery, but a full 30% would have seen a plastic surgeon if it were offered. It is apparent from these surveys that a disconnect is occurring between plastic and breast surgeons. Failure to adopt oncoplastic surgical techniques in the United States and Canada could in part be due to the breast surgeons’ lack of knowledge of these techniques. When surveyed regarding the desire to learn oncoplastic techniques, 99% of breast surgeons indicated an interest in learning the techniques with 77% being extremely interested. Seventy percent of polled breast surgeons believed adoption of oncoplastic techniques would be dependent upon training breast surgeons in those techniques, and 52% thought increasing awareness for breast surgeons using oncoplastic techniques as they work with plastic surgeons would improve adoption of oncoplastic surgery techniques.

The simplistic definition of oncoplastic surgery is the best oncologic surgery with the best cosmetic result. Another clarifying definition: “oncoplastic surgery is surgery that is considerate to what we leave women to live with for the rest of their lives and should be an integral part of treatment for all women with breast cancer.” Why would any surgeon not consider this for every patient? Which patient deserves less than the best aesthetic result?

To suggest oncoplastic techniques are merely specific procedures would do the field of oncoplastic surgery a great injustice. Instead, oncoplastic surgery begins as an embraced philosophy as the surgeon collaborates with other surgeons in the care of the patient. The ability to evaluate a woman’s breast and consider all the possible surgical approaches for the removal of cancer and restoring the appearance of both breasts is mentored and developed through sharing these techniques. The spectrum of options from basic to advanced will require skill sets of both breast and plastic surgeons. As the breast surgeon discovers the benefits of the basic oncoplastic techniques, the surgeon will also understand the importance of partnering with plastic surgeons to rely on their expertise for appropriate patient treatment.

Training breast surgeons to perform basic principles in oncoplastic surgery will be the start to ensure the best aesthetic result for every woman undergoing breast cancer surgery.