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INTRODUCTION: Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described. OBJECTIVE: We aimed to compare the costs of eOBCS and mastectomy. METHODS: We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included. RESULTS: Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416. CONCLUSION: eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.
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INTRODUCTION: Patients with multiple or large malignant breast lesions are classically considered mastectomy candidates, but extreme oncoplastic breast-conservation surgery (eOBCS) has become an alternative approach. There is a paucity of outcomes data comparing eOBCS with mastectomy. METHODS: We reviewed our prospectively maintained, single-institution database. We included patients with non-metastatic breast cancer with multiple ipsilateral or single large (≥ 5 cm) malignant breast lesions identified preoperatively who underwent either eOBCS or mastectomy. Patient demographics, clinicopathologic features, and surgical, oncologic, and cosmetic outcomes were evaluated. RESULTS: Seventy-six (88%) patients underwent eOBCS and 10 (12%) underwent mastectomy. Median follow-up was 24.8 months. Mastectomy patients had larger lesions than eOBCS patients (median 70 mm vs. 32.5 mm; p = 0.06). Six (60%) index mastectomy patients underwent at least one additional surgery. For eOBCS patients, 34 (44%) required re-excision, 7 of whom underwent more than one subsequent surgery to obtain negative margins, and 6 (7.9%) ultimately underwent mastectomy. For patients undergoing additional surgery (n = 40), median time between index and final operation was 315 days for mastectomy versus 21 days for eOBCS patients (p < 0.001). Mastectomy patients more frequently experienced complications (p = 0.001) and underwent cosmetic revision (p < 0.001). There was no difference in cosmetic scores, and eOBCS patients reported less pain (p = 0.009). There were two local and three distant recurrences in the eOBCS cohort and one distant recurrence in the mastectomy group. CONCLUSION: Breast conservation was attainable in over 90% of eOBCS patients. Increased postoperative complications and discomfort and longer duration of surgical treatment in mastectomy patients without oncologic superiority should drive informed patient discussions.
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INTRODUCTION: In the era of oncoplastic breast conserving-surgery (OBCS), cosmetic outcomes and the desire for symmetry have become essential elements of the surgical management of breast cancer (BC). The timing of contralateral symmetry procedures remains a controversial topic. Simultaneous symmetry procedures (SSP) in OBCS have not been routinely offered due to the perceived risk of delayed asymmetry, potentially increasing the need for delayed cosmetic revision. This study evaluates the rate of revision after SSP in patients undergoing OBCS. METHODS: We reviewed our institutional prospectively maintained database identifying all BC patients treated surgically since our introduction of oncoplastic surgery in 2018. We routinely offer SSP when appropriate. Descriptive statistics evaluated oncoplastic surgical techniques, SSP offerings and procedures, perioperative complications, and revision rates after treatment completion. RESULTS: Between 2018 and 2022, 485 breast cancer patients underwent partial mastectomy, and 396 (82%) underwent OBCS. Of the 313 patients offered SSP, 272 (87%) accepted. The margin reexcision rate of this cohort was 20%. Of the 272 patients with SSP, 152 (56%) underwent intraoperative radiation therapy (IORT), and 105 (39%) had adjuvant external beam radiation therapy. Three patients (1%) experienced complications involving the symmetry side. No patients with complications experienced a delay in adjuvant therapies or requested cosmetic revisions. Three patients (1%) desired surgical revisions due to asymmetry. CONCLUSIONS: Symmetry procedures at the time of OBCS are widely accepted by patients and rarely require delayed cosmetic revision. Simultaneous symmetry procedures should be routinely discussed with patients during the surgical planning of OBCS.
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Breast Neoplasms , Mammaplasty , Female , Humans , Breast Neoplasms/surgery , Combined Modality Therapy , Mammaplasty/methods , Mastectomy/methods , Mastectomy, Segmental/methods , Retrospective StudiesABSTRACT
BACKGROUND: The incidence of occult breast cancer among patients undergoing reduction mammoplasty or risk-reducing mastectomies ranges from 1% to approximately 10%, respectively. Identification of incidental cancer often mandates subsequent mastectomy due to ambiguous margins. This study aimed to determine the incidence of contralateral malignancy among patients undergoing oncoplastic breast-conserving surgery (OBCS) with concurrent symmetry procedures. METHODS: The authors reviewed their prospectively maintained institutional database of patients with unilateral breast cancer who underwent OBCS. Patients who underwent excisional biopsy on the contralateral breast were analyzed separately. Patient demographics, pathologic features, and subsequent disease management were evaluated. RESULTS: Between March 2018 and July 2022, 289 patients underwent OBCS with a symmetry procedure, and 100 patients yielded contralateral breast tissue specimens. For 14 patients, a planned excisional biopsy was performed with their symmetry procedure, and five lesions (36%) were found to be malignant. Of the remaining 86 patients, 92% underwent preoperative breast magnetic resonance imaging (MRI). Four patients (4.7%) had occult malignancies identified on the contralateral breast pathology; three patients with ductal carcinoma in situ and one patient with invasive lobular carcinoma. Three patients had undergone preoperative MRI without suspicious findings. No patients required mastectomy for treatment of the contralateral breast cancer. CONCLUSION: The incidence of occult malignancy among OBCS symmetry procedures approaches 5%. The final pathology of excisional biopsies had a higher upgrade rate than previously reported. All identified malignancies were early-stage disease. The higher incidence of occult breast cancer in this population warrants the routine orientation of all specimens, which allows patients with incidental early-stage cancer the option of breast preservation.
Subject(s)
Breast Neoplasms , Carcinoma, Intraductal, Noninfiltrating , Mammaplasty , Neoplasms, Unknown Primary , Humans , Female , Breast Neoplasms/epidemiology , Breast Neoplasms/surgery , Breast Neoplasms/pathology , Mastectomy/methods , Mastectomy, Segmental , Mammaplasty/methods , Carcinoma, Intraductal, Noninfiltrating/surgery , Neoplasms, Unknown Primary/surgery , Retrospective StudiesABSTRACT
BACKGROUND: Randomized, controlled trials comparing breast-conserving therapy (BCT) with mastectomy have demonstrated equivalent overall survival (OS), but recent observational studies have shown improved OS in patients undergoing BCT. These studies provide limited data on young patients who are traditionally offered mastectomy due to perceived higher disease risk. This study examines the OS in a contemporary series of young women with breast cancer undergoing upfront BCT compared with mastectomy. METHODS: Women ≤40 years old with primary invasive T1-T2, N0-N1 breast cancer were identified from the National Cancer Database between 2006 and 2016. Patient cohorts were based according to locoregional treatment: BCT, mastectomy alone (Mx), and mastectomy with radiotherapy (Mx/RT). Kaplan-Meier method followed by Cox proportional-hazards regression with inverse probability of treatment weighting (IPTW) were performed to account for treatment selection bias effects in OS. RESULTS: A total of 15,611 patients met the study criteria; 9,509 patients (60.9%) had BCT, 4,020 (25.8%) had Mx/RT, and 2,082 (13.3%) had Mx alone. The median follow-up was 4.6 years (interquartile range [IQR] 3.0-6.4). After IPTW-adjustment, the 5-year OS was similar for BCT (95%), Mx (95%), and Mx/RT (94%), and there was no significant difference in OS in Mx (hazard ratio [HR] = 1.16, 95% confidence interval [CI] 0.90-1.51) and Mx/RT (HR = 1.08, 95% CI 0.88-1.34) compared with BCT. Mx/RT was associated with decreased survival in patients with pT2N0 (HR = 1.78, 95% CI 1.12-2.84). CONCLUSIONS: Among young patients with early-stage breast cancer, overall survival was equivalent regardless of surgical approach. Breast-conserving therapy remains a safe option in young women despite the clinical tendency to offer upfront mastectomy in young patients.
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Breast Neoplasms , Mastectomy , Adult , Breast Neoplasms/surgery , Combined Modality Therapy , Female , Humans , Mastectomy/methods , Mastectomy, Segmental/methods , Proportional Hazards ModelsSubject(s)
Breast Neoplasms , Mammaplasty , Humans , Female , Mastectomy, Segmental/methods , Breast/surgery , Mammaplasty/methodsSubject(s)
Breast Neoplasms , Breast , Breast Neoplasms/surgery , Female , Humans , Mastectomy, SegmentalABSTRACT
this is a 10-year retrospective chart review evaluating the potential impact of the most recent American Cancer Society mammography screening guidelines which excludes female patients aged 40 to 44 years from routine annual screening mammography. Instead they recommend screening mammography starting at age 45 with the option to begin screening earlier if the patient desires. The institutional cancer registry was systematically searched to identify all women aged 40 to 44 years treated for breast cancer over a 10-year period. These women were separated into two cohorts: screening mammography detected cancer (SMDC) and nonscreening mammography detected cancer (NSMDC). Statistical analysis of the cohorts was performed for lymph node status (SLN), five-year disease-free survival, and five-year overall survival. Women with SMDC had a significantly lower incidence of SLN positive cancer than the NSMDC group, 9 of 63 (14.3%) versus 36 of 81 (44 %; P < 0.001). The five-year disease-free survival for both groups was 84 per cent for SMDC and 80 per cent for NSMDC; this was not statistically significant. The five-year overall survival was statistically significant at 94 per cent for the SMDC group and 80 per cent for the NSMDC group (P < 0.05). This review demonstrates the significance of mammographic screening for early detection and treatment of breast cancer. Mammographic screening in women aged 40 to 44 detected tumors with fewer nodal metastases, resulting in improved survival and reaffirming the need for annual mammographic screening in this age group.