2 Current Approach to Oncoplastic Breast Surgery

10.1055/b-0037-144847

2 Current Approach to Oncoplastic Breast Surgery

The European Experience

R. Douglas Macmillan

Advances in the management of breast cancer over the past 30 years are so significant that modern practice now bears little resemblance to its earlier form. There are many reasons for this, but the effective alliance of all the varied specialties that treat the disease is an important one.

Breast surgery is now a completely different entity for current surgeons than it was for the generation that preceded them, and the difference is most stark for those who practice oncoplastic surgery.

What then are the key milestones in the evolution of oncoplastic surgery? This term was originally coined to reflect the integration of chemotherapy and radiotherapy planning with conservative forms of breast surgery for more advanced disease, but now it is used ubiquitously to describe surgery that aims to maintain quality of life and breast appearance while being uncompromising on oncologic effectiveness. ¹ The cosmetic outcome of breast cancer surgery has not always been viewed as a priority, with survival itself being the overriding concern. Perhaps then the early developments in oncoplastic surgery served to show that even in locally advanced disease, obvious deformity could be safely avoided.

As survival from breast cancer has become the outcome for the large majority of patients, attention has correctly focused on the consequences of surgical treatment, both short and long term, not just the effectiveness of it. In other words, what do we leave women to live with for the rest of their lives? Breast cancer has so many negative connotations and insults to a woman’s sense of being whole that it seems startlingly obvious that if the negative impact of surgery can be mitigated, then it should.

The first major step in this regard was the widespread use of breast-conserving surgery as an alternative to mastectomy. Offering a choice in this regard and expanding the indications for breast conservation was a key goal of oncoplastic surgery. Some of the milestone innovations that developed this goal were:

The use of breast reduction techniques, initially to remove cancers that were located in areas of the breast that could be removed as part of a standard reduction technique, but later to include the use of modified techniques to allow resection of any part of the breast
Volume replacement techniques, initially using variations on latissimus dorsi flaps, but later using local perforator-based flaps
Various techniques to allow en bloc closure of breast defects from simple patterns of skin reduction to modifications of cosmetic mastopexies

Most of these techniques were developed in Europe. ² – ⁸

The many pioneers of oncoplastic surgery had a common background and overcame a common hurdle: they had training that enabled them to apply plastic surgery techniques to the surgery that was required oncologically, and they had developed a practice that enabled breast oncologists and breast plastic surgeons to work in harmony. By showing what was possible, these pioneers inspired others to follow. However, to emulate their example and widen the net for who could be offered oncoplastic surgery, it was essential to challenge the traditional two-surgeon model where one surgeon “made a hole” and another surgeon “filled it.” The flaws and limitations in that approach only really become obvious to those who practice it once other methods of service delivery are experienced.

Oncoplastic surgery has to be considered, planned, and indications for different techniques recognized at the point of primary presentation and treatment planning.

Essentially, all breast surgery needs to be viewed as oncoplastic. We would ask why anyone without aesthetic skills would operate on the breast and why anyone without oncologic knowledge should operate on a breast cancer patient. The logic of this argument is surely incontestable. However, that is not to say that any one surgeon can offer all options, because no one can; breast surgery will always require a mixture of oncologic, plastic, and microsurgery skills provided by a team of specialists.

The point is more that any surgeon performing breast cancer surgery requires a minimum skill set; this has to include knowledge of all techniques and working ability in many of the techniques of breast oncology and breast plastic surgery.

For all this to happen, traditional territorial divides needed to be challenged. Those who benefit from the surgery that can now be offered owe much to those who navigated through this minefield. Again, Europe appears to have led the way.

Globally, the biggest barrier to oncoplastic surgery is the degree to which the specialties of breast surgery and plastic surgery prioritize their own self-interest. Harsh though this sounds, and though many would not admit it and no one would intentionally wish this, the tribalism that is perpetuated in many countries is the main reason that oncoplastic surgery has not developed at the rate it should.

It is difficult to overstate the significance of this factor or the detrimental effect it has on the quality and choice of surgery that is offered to women. In many countries it has required a generational shift in attitude and a slow attrition of the stalwarts who wish to keep things as they are. In all countries that have made progress, it has required challenges to dogma and the generous sharing of knowledge and skills.

There are perhaps many reasons that oncoplastic surgery has flourished in Europe more than other regions, but the main one has probably been overcoming the difficulties outlined previously at an earlier stage and at a more rapid rate. Increasing specialization amongst breast and plastic surgeons is another.

However, making the transition to oncoplastic surgeon from either a plastics or breast oncology background is not an easy one, and it takes time. Hence another critical reason in the United Kingdom, and in Europe has helped oncoplastic surgery develop, is the creation of integrated training fellowships.

The concept of an oncoplastic breast surgeon coming from a background of general, oncologic, or plastic surgery and acquiring cross-specialty skills that were previously unique to the parent specialty started to gain momentum in the United Kingdom in the late 1990s. Two key factors were catalytic in advancing this concept: recruitment difficulties in breast surgery, and a new oncoplastic interface training initiative. Foreshortened training programs, a shorter working week, and an increase in consultant numbers stripped the breast surgeons in the United Kingdom of the wide skill base of the general surgeon. These were not replaced by other technical skills and challenges, and as a result, by the end of the twentieth century, breast surgery became an increasingly unattractive option for trainees who regarded it as technically unchallenging compared with other specialties. ⁹ In some cases, this led to its being an attractive specialty for less technically gifted surgeons, a situation not in the interests of women with breast cancer. This issue was addressed in 1996 in the United Kingdom’s revised Specialist Advisory Committee’s curriculum for general surgical trainees with a subspecialty interest in the breast, which for the first time included a comprehensive reconstruction module. ¹⁰ It was the first curriculum in Europe to include such a module.

Of the few trainees selecting breast surgery as a career at that time, 84% wished to acquire technical skills in breast reconstruction. ⁹ In response to a proposal made by the Association of Breast Surgery to the Council of the British Association of Plastic Surgeons, an “Interface” Breast–Plastic Surgery Training Group was established in 2000. The concept of an oncoplastic or “total” breast surgeon trained in all aspects of diagnosis, resection, reconstruction, and clinical management was born. The stated goals of the Interface Group are threefold:

To improve service to patients by facilitating interface training.
To develop cross-specialty training opportunities for specialist registrars and consultants.
To move training in oncoplastic surgery to an earlier stage in a trainee’s career.

Ultimately, a different model of training for breast surgeons is required that does not rely on acquisition of traditional general surgery skills, most of which are not relevant to oncoplastic breast surgery.

These goals underpinned a successful proposal to the United Kingdom Department of Health to fund nine new training fellowships in oncoplastic surgery. Senior-level trainees were appointed for 12 months to large multidisciplinary oncoplastic training centers in England. The program, now expanded, has increasingly become the recognized pathway for general and plastic surgeons to pursue a career in oncoplastic breast surgery.

While much of the early emphasis of oncoplastic surgery was on providing better outcomes in breast-conserving surgery and expanding the indications for it, an equally important development was seen in mastectomy and breast reconstruction.

The ability to perform an oncoplastic mastectomy is a basic requirement of any oncoplastic surgeon, whether they be breast oncology or plastics based. It is a much more difficult skill to acquire than many assume and is the basis of any good reconstruction. Inadequately performed, it is also the basis of most early complications. The application of the many techniques available to achieve good functional and aesthetic outcomes from any form of mastectomy, with or without immediate reconstruction, has enabled a dramatic improvement in the quality of reconstructions. Importantly, oncoplastic training has led to a significant increase in rates of breast reconstruction. A diverse skill set has been crucial, and although a team approach is required so that all appropriate options can be offered and combined operating is often useful, the two-surgeon model is restrictive and inefficient.

Clearly, the specific specialty providing these services is less important than the standard of training and experience of the teams performing these techniques.

The current approach to oncoplastic surgery in Europe varies from country to country and within countries.

The model posited by many as the ideal is that of a surgical team whose individual members are trained in either general or plastic surgery but who are all oncoplastic surgeons and have considerable skill overlap.

Another common model is based around a team of oncoplastic surgeons providing almost all aspects of the service, with separate microsurgery input. In places where the two-surgeon model still exists, the input of plastic surgery is increasingly sought, but the limitations of a nonintegrated skill set are obvious. There will be many local reasons for different models of service delivery, and one will not fit all. However, oncoplastic surgery is definitely now the norm, and the results, and increasingly the patients, provide the momentum to drive the specialty forward.

With the advances in service delivery and the quality of outcome offered, patient expectations have been raised, and this should be seen as a motivator to further improve quality rather than as a burden. We have not yet achieved what can ultimately be offered with oncoplastic surgery, but the countries that have been slow to adopt these newer models begin to look like lapped back-runners in a rapidly expanding field where new techniques and technologies are continually being integrated.

The need to more clearly define and validate standards, to better accredit training, to support continued professional development, and to evaluate practice has become a priority.

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