LAUSR

I read with interest a recent article published in this Journal by Dr. Acea-Nebril et al. regarding “The role of oncoplastic breast reduction in the conservative management of breast cancer: complications, survival, and quality of life.” The authors have correctly pointed out that there is a paucity of long-term outcome data comparing tumorectomy and reduction mammoplasty (RM). Hence, their timely study is commendable. In their analysis, it is particularly intriguing to note that while there was no difference in overall survival at 10 years, poorer local control rate was demonstrated with RM. This may be related to a higher proportion of women in more advanced stages of disease who underwent RM, although information is lacking with respect to adjustment for confounding factors. Nevertheless, the study does provide indicative data that RM is not definitively superior to tumorectomy or standard breast conserving treatment (sBCT) in terms of local control. In this study, tumorectomywas performed for womenwith cancer smaller than 3 cm at diagnosis or after neoadjuvant chemotherapy, in locations associated with a low risk of deformity. It was noted that 58.9% of women with T1 lesions, and a total of 23.5% of the study cohort with T2 and T3 tumors underwent RM had. Almost seventyeight percent (77.9%) having RM did not undergo primary chemotherapy. It is unclearwhether the tumor size classificationwas taken preor post-neoadjuvant treatment, but the relative proportions would suggest that not all of the patients who underwent RM had neoadjuvant therapy. Neoadjuvant treatment has been demonstrated to be efficacious in downstaging tumors, rendering patients initially requiring a mastectomy at presentation, to suitable candidates for breast conservation treatment, successfully effecting de-escalation of surgical therapy. If all patients in the current study with lesions larger than 2 cm in this cohort were offered neoadjuvant medical treatment, could sufficient downstaging have resulted such that more patients had disease amenable to tumorectomy rather than RM? Perhaps patients with preoperative tumor sizes of 2 cm or smaller could have been offered tumorectomy using “minimalist” breast conserving surgery approaches. For T1 lesions sited in the central and lower hemisphere of the breast, instead of using the vertical or wise pattern mammoplasty, surgerymay be simplified using the golf-tee, anchor and elliptical central incisions with particular resection patterns to achieve tumorectomy with clear margins and acceptable cosmesis. In this way, a significant proportion of patients might be spared the longer operating time, more prolonged hospital stay and higher risk of nipple necrosis if an RM procedure were converted, or de-escalated, to tumorectomy. The objective of RM use is the attainment of acceptable cosmetic outcomes. Unfortunately, what constitutes “acceptable cosmetic outcomes” is yet undefined and differs when evaluation is performed by specialists, software programmes, or patients themselves. There is some data to suggest that patients are more likely to rate their cosmetic results as “excellent” after standard breast conservation treatment than surgeons. Moreover, significantly more patients may rate cosmetic outcomes of scars with sBCT better than mastopexy. This finding is consistent with another study by Dr. Acea-Nebril et al. where the possibility of poor cosmetic outcomes with various forms of oncoplastic and breast reduction surgical approaches was detailed. Although RM may allow improved cosmetic outcomes in certain situations, the work by Dr. Acea-Nebril et al. highlights the fact that local control may not be superior. As alluded to in the foregoing discussion, patients who undergo RM are subject to longer operating times, higher risk of complications for the sake of better aesthetics, benefits which may not be perceived by patients. There are contemporary means of reducing the requirements for RM through the use of primary medical therapy and certain surgical techniques to avoid poor cosmesis when tumors are sited at “risk” locations. Despite the availability of such modern medical technology to expand the indications for tumorectomy, there is still strong advocacy for routine RM. This behoves the question as to whether the frequent use of RM is surgeon driven, rather than patient-outcome driven, and whether there is an element of overtreatment when appropriate measures have not been undertaken to reduce extent of surgery. In an era where de-escalation of therapy without compromise of outcomes is upheld as the ideal management goal, there appears to be some contradiction in our stance as surgeons in promoting RM. Such a conundrum offers opportunities for further evaluation on how the surgeon factor impacts treatment outcomes.