Breast reconstruction is a complex and often, multidisciplinary treatment option for patients undergoing breast cancer operations in Australia. For years, the rates of post mastectomy reconstruction have remained very low at around 6% (1), despite an abundance of technical skills and expertise in most major Australian metropolitan centres.
Approximately 40% of patients will undergo mastectomy as part of the surgical treatment of their Breast Cancer (3).
It is well known that mastectomy can have a negative impact on body image and sexual function. Immediate and delayed breast reconstruction has been shown to decrease negative emotional and psychological consequences of mastectomy, thereby reducing anxiety, improving self-esteem and enhancing the quality of life of these patients.
Breast reconstruction has also been shown to be oncologically safe in the majority of patients (3). Multiple reasons have been proposed for low post-mastectomy reconstruction uptake. It seems that a combination of restricted access, high cost and being considered a secondary priority has all contributed to this (2).
Studies have also consistently found that women who are younger, better educated, of higher socioeconomic status and from non-ethnic minority groups are much more likely to undergo reconstruction (3).
How oncoplastic breast surgery is increasing patients’ access to reconstruction.
The oncoplastic revolution is helping provide patients increased access to reconstruction. Breast reconstruction is now considered an essential part of treatment for breast cancer by specialists and is discussed with patients suitable for this from the outset.
Also, the advent of implant-based breast reconstruction and immediate, single or two stage procedures has contributed to rising rates of reconstruction in Australia, which doubled to 12% nationwide in 2008, propagated by Oncoplastic and Plastic Surgeons interested in this field, with some specialised oncoplastic practices having reconstruction rates up to 41% (5).
The up-skilling of oncoplastic surgeons means that many more women have access to reconstruction and, importantly, this is often performed as part of the same operation as the cancer resection, minimising the number of trips to theatre for the patient.
Seamless transition between resection and reconstruction is of significant importance to many patients and generates a lot of interest and discussion. Single surgical team approach as opposed to multiple teams improves logistical surgical planning and therefore patient convenience7.
The oncoplastic surgery revolution means that a group of appropriately trained Oncoplastic Breast Surgeons are now able to provide this important service. The level of expertise varies among these surgeons depending on experience and training; however, most are able to perform implant-based reconstructions and a small proportion are also trained to perform flap-based reconstructions (6).
Regardless of their technical expertise, they are all familiar with various aspects of reconstruction and can discuss these options with patients, to facilitate an appropriately informed decision. Oncoplastic Breast Surgeons possess the necessary skills and also the expertise in the management of breast cancer and its sequela and can offer a number of reconstructive alternatives to the patient.
Therefore, if a patient expresses an interest in breast conservation with superior aesthetic outcomes, or wishes to discuss reconstruction options an Oncoplastic Breast Surgeon is an important resource to be utilised.
A CASE STUDY
Recently I treated a 50-year-old woman who was diagnosed with left breast cancer through Breast Screen NSW. It appeared to be an early cancer under 20mm in diameter, with hormonal receptor status unknown at presentation, with no obvious local or distant metastases. The patient was an anxious person, otherwise fit and well, wishing to avoid radiotherapy if possible.
After extensive discussions, she chose to go ahead with a bilateral, nipple-sparing mastectomy and an immediate single stage reconstruction using implants and acellular dermal matrices. She was able to have this procedure performed under one general anaesthetic by a single Oncoplastic Surgeon team. She spent four days in the hospital with an uneventful recovery and was seen in rooms thereafter, making a good recovery.
Final pathology suggested that she indeed could avoid radiotherapy and chemotherapy, but will need anti-hormonal treatment due to the presence of hormonal receptors. She was able to have all her surgical treatment completed in a single procedure and then go on to have her adjuvant treatment unremarkably.
This patient highlights the benefits that can be achieved by streamlining reconstruction as part of the initial resection surgery, which is possible for many patients these days. She achieved good oncologic and aesthetic outcomes with a good prognosis for her breast cancer.
The rate of breast reconstruction in Australia remains low, despite its proven benefits and strong worldwide recommendations in support of reconstruction. Oncoplastic Breast Surgeons can help improve access to this procedure for the majority of patients and improve the overall uptake and streamlining of breast Reconstruction in the treatment of breast cancer.
1 Williams P, Rankin N, Redman S et al. National Consumer Survey of the Perceptions of Care of Women with Breast Cancer. Canberra: National Breast Cancer Centre, 2003
2 Sandelin K, King E, Redman S, Breast Reconstruction Following Mastectomy: Current Staus in Australia, ANZ J. Surg.2003; 73: 701–706
3 M.E. Brennan, A.J. Spillane , Uptake and predictors of post-mastectomy reconstruction in women with breast malignancy e Systematic review EJSO 39 (2013) 527e541
4 Cancer Australia. NBCA – NBOCC and RACS National Breast Cancer Audit Public Health Monitoring Series 2008 Data. [Cited 10 July 2012.] http://canceraustralia.gov.au/publications-resources/cancer-australia-publications/nbocc-and-racs-national-breast-cancer-audit-public-1
5 Wong, Snook, Brennan et al, Increasing breast reconstruction rates by offering more women a choice ANZ J Surg 84 (2014) 31–36
6 Urban CA. New classification for oncoplastic procedures in surgical practice. Breast 2008; 17: 321e2.
7 French J and Elder E, Letters to the Editor, ANZ J Surg 84 (2014) 693–697