Introduction

Currently 40% of the 55,000 UK women [1] diagnosed with breast cancer each year undergo mastectomy [1] of whom only 1 in 4 have reconstruction [2]. Oncoplastic breast-conserving surgery (OPBCS) describes a range of volume replacement (e.g. local perforator flaps (LPFs)) and volume displacement techniques (e.g. therapeutic mammaplasty (TM)) that combine removing the cancer with plastic surgical techniques to reconstruct and reshape the breast. These newer techniques can improve cosmetic outcomes and extend the role of BCS, allowing some who would not be suitable for standard breast-conserving surgery due to the size of the excision needed to remove the cancer to avoid mastectomy [3, 4]. High-quality comparative evidence to support OPBCS as a means of extending the roll of BCS to include those who have been traditionally managed by mastectomy ± immediate breast reconstruction (IBR), however, is currently lacking. Previous work comparing short-term clinical outcomes of TM in 376 women offered the procedure to avoid mastectomy in the TeaM study [5] and 2540 patients undergoing mastectomy ± IBR in the iBRA-2 study [6] suggests that although patients in the TM group were ‘higher risk’, they were significantly less likely to develop major complications requiring readmission or reoperation than those undergoing Mastectomy + IBR [7] and there is emerging evidence to support cost effectiveness [8, 9].

Whilst these results are encouraging, there remains a need for high-quality studies directly comparing the clinical and patient-reported outcomes of OPBCS as an alternative to mastectomy ± IBR in women not suitable for standard BCS. Randomised trials [10] in this context are not feasible due to patient and surgeon preference, so a large-scale prospective cohort study is needed. It is vital, however, that the study reflects current UK practice and includes outcomes that are important to patients and healthcare professionals. Currently there is limited data on OPBCS practices across the UK with no national database on practices or guidelines [3, 11]. Little information is known on the number of OPBCS procedures performed in the UK, the selection criteria, approaches to contralateral symmetrisation and what factors are considered as absolute or relative contraindications for OPBCS.

The ANTHEM feasibility study [12] aims to inform the design of a future large-scale study. It has four parts: (1) National practice questionnaire (NPQ), (2) pilot prospective cohort study, (3) qualitative interview study and (4) design of future study [12]. We report here the results of the first part of the ANTHEM feasibility study, the NPQ which aimed to survey breast and plastic surgical units across the UK to comprehensively describe the current practice and provision of OPBCS (TM/LPF) to help inform future study design.

Methods

The national practice questionnaire (NPQ, Online Appendix 1) was developed in REDCap [13] by the ANTHEM steering group to explore the current practice of OPBCS and mastectomy ± IBR. The survey included the local availability of volume displacement/replacement techniques; numbers of cases performed; contraindications and approaches to contralateral symmetrisation. As the survey was primarily focussed on the provision of OPBCS to allow women to avoid mastectomy, participating units were asked to include only level 2 OPBCS procedures. Level 2 procedures were defined as volume replacement with local perforator flaps and/or volume displacement using breast reduction or mastopexy techniques.

All breast and plastic surgery units in the UK were invited to participate. The ANTHEM NPQ was distributed via the professional associations (Association of Breast Surgery (ABS), National Trainee Research Collaborative (NTRC) and the Mammary Fold Academic & Research Collaborative (MFAC). The professional associations endorsed the study and encouraged unit participation. Respondents were asked to complete one survey per Unit, so responses reflected the practices of the Unit as a whole rather than those of an individual surgeon. Multiple responses from the same individual and from the same unit were excluded from the study. The most complete response was taken as that unit’s entry for the analyses. Non-responding units were encouraged to respond to the questionnaire by reminders in ABS and MFAC newsletters but were not directly approached.

Analysis

Descriptive summary statistics were calculated for each survey item to evaluate the availability, volume and indications for each type of oncoplastic procedure. No data imputation methods were used for missing data. When a unit did not complete a specific section of the questionnaire, it was assumed that the unit did not offer that approach.

Results

Participation and unit characteristics

Between July 2020 and December 2021, 58 units completed the NPQ. Of these, 43/58 (74%) were stand-alone breast units and 15/58 (26%) combined breast and plastic units (Table 1). Most participating units were combined symptomatic and breast screening units (48/58, 83%) staffed by four to six consultant breast surgeons (28/58, 48%) treating more than 500 cancers per year (n = 24) (Table 1). Of the participating combined breast and plastic units (n = 15), all had access to at least one plastic surgeon with a special interest in breast surgery work within the unit (Table 1).

Table 1 Characteristics of participating units
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Current practice of level 2 oncoplastic procedures

Unit approaches to level 2 OPBCS procedures (TMs and LPFs) are summarised in Table 2. The majority of participating units (56/58, 97%) offered volume displacement techniques (therapeutic mammaplasty) (including wise pattern; vertical scar techniques, etc.) and over two-thirds (39/58, 67%) routinely offered local perforator flaps (LPFs) (e.g. Lateral intercostal artery perforator (LiCAPs) flaps/Lateral thoracic artery perforator (LTAPs) flaps) (Table 2). Of those units not currently performing LPFs, approximately half (10/19) were planning to introduce the technique within the next 12–24 months. Most units reported having several surgeons who were able to perform volume displacement procedures and approximately half of responding units performed 50 or more TM procedures per year. By contrast, fewer surgeons at responding units were able to offer LPFs/volume replacement procedures and fewer procedures were reported as being performed each year (Table 2). Of those units performing LPF procedures 24/38 (63%) usually performed as a one stage procedure, 4/38 (10%) usually as a two-stage procedure and 10/38 (26%) were dependant on patient and tumour characteristics.

Table 2 Local provision of level 2 oncoplastic breast-conserving surgery (OPBCS) (n = 58 participating units)
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Approaches to contralateral symmetrisation in patients undergoing TM

Approaches to contralateral symmetrisation in patients undergoing TM were highly variable. Approximately a third (n = 19/54, 35%) of units routinely performed simultaneous contralateral symmetrisation most commonly with two-surgeon operating (11/19, 58%) but a quarter (13/54) routinely planned contralateral symmetrisation as a delayed procedure following completion of adjuvant treatment (Table 3). A significant proportion of units (15/54, 28%) reported discussing the timing of contralateral symmetrising procedures with patients on a case-by-case basis. The two main reasons given for performing contralateral symmetrisation as a delayed procedure were theatre capacity issues limiting access for bilateral surgery (reported by 8 units) and the perception that better symmetry was achieved following completion of radiotherapy (RT) (reported by 11 units). If contralateral symmetrisation was discussed with patients on a case-by-case basis the main factors influencing decision-making were reported as possible risk factors for complications (e.g. BMI, smoking etc.), patient choice, likely need for adjuvant chemotherapy and the degree of asymmetry (Table 3).

Table 3 Approaches to contralateral symmetrisation in patients undergoing therapeutic mammaplasty (TM)
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Contraindications to OPBCS (TMs and LPFs)

Participating units were also asked to report what they considered as contraindications to TMs and LPFs procedures in their unit (recorded as either absolute contraindication, relative or not a contraindication), factors included current smoking, high BMI, connective tissue disease and current steroid use. For TMs, over two-thirds of units (between 34 and 40 units/54, 63–74%) did not consider any of these factors to be a contraindication to TM (Fig. 1). High BMI was considered an absolute contraindication in approximately one-third of all units (18/54, 33%), with current steroid use, connective tissue and current smoking all considered absolute contraindications in 15%, 11% and 17% of units, respectively (Fig. 1). Other reported contraindications to TMs included multicentric disease, previous surgery and radiotherapy, poorly controlled diabetes, age over 70 and adverse scarring of breast.

Fig. 1
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Unit contraindications to therapeutic mammaplasty and chest wall local perforator flaps

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Approximately half of units performing chest wall perforator flaps considered high BMI (17/37, 46%) and current smoking (21/37, 57%) to be absolute or relative contraindications to the procedure (Fig. 1). Current steroid use and connective tissue disease were not commonly considered to contraindicate the procedure. Other reported contraindications included Raynaud’s disease, diabetes (relative contraindication), poor vascular flow, significant co-morbidities and previous thoracotomy.

Finally, units were asked about oncological contraindications to OPBCS and whether local multidisciplinary teams (MDT) would support BCS in specific scenarios (Fig. 2). Most units supported OPBCS for multifocal disease (98%) and large tumours (96%). Approximately two-thirds of units (65%) would offer OPBCS for multicentric disease and over three-quarters would offer the procedure for extensive DCIS (Fig. 2).

Fig. 2
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MDT support for Oncoplastic breast-conserving surgery (OPBCS) in different scenarios

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Discussion

This study has provided a valuable insight into the current practice and provision of oncoplastic breast-conserving surgery (OPBCS) across the UK. The survey suggests that TM/volume displacement procedures are widely available across the UK with 97% of participating units currently staffed by multiple surgeons who are able to offer this procedure. By contrast, only two-thirds of the participating centres offered LPF procedures with fewer surgeons able to perform the procedure at each Unit. This is likely to reflect the relative novelty of the procedure as the majority of units not currently offering LPF were planning to introduce it into their practice in the near future indicating a desire to expand and develop this relatively new surgical technique. The overall volume of OPBCS procedures reported here is in contrast to the findings of the recent Getting it Right First Time report in breast surgery which suggested that less than 10% of all BCS procedures performed were oncoplastic [1]. This is likely to reflect the way that such operations are coded in the UK and a need for improvement in this area.

There was, however, considerable variation in participating units’ approaches to contralateral symmetrisation in patients undergoing TM procedures. Only a third of units routinely performed simultaneous contralateral symmetrisation at the time of the TM with the remainder either offering symmetrisation as a planned delayed procedure or considering the timing of symmetrisation on a case-by-case basis. Reasons for this were multifactorial but concerns about complications and the perception that better symmetry would be achieved following completion of radiotherapy. These findings are consistent with the previous survey findings [14] and appears to be a common approach [15]. However, data to support this practice are lacking. There was limited evidence to suggest that complication rates after simultaneous contralateral symmetrisation were higher, even in high-risk patients in the UK TeaM study [5]. Logistical and resource constraints, however, are likely to be important considerations in unit decision-making as highlighted in this study. In a resource-constrained NHS setting, hospitals may have incentives not to offer simultaneous contralateral symmetrisation, as the procedure is resource intensive requiring longer operating times or additional surgeons [16]. This may be particularly relevant in smaller units as the majority of units routinely offering bilateral surgery used a two-surgeon approach, which may only be feasible in a larger unit.

Variability between units was also observed in reported relative and absolute contraindications to TMs and LPFs. High BMI and smoking were the most common contraindications and have been shown to be associated with an increased risk of complications after TM procedures [5]. The impact of reported contraindications on the outcomes of LPF, however, is currently unknown. Larger prospective studies are needed to determine best practice to allow predictors of complications to be assessed.

Finally, this work highlighted that OPBCS is considered an oncologically safe option in the majority of settings including for large tumours, multifocal disease and in women with large areas of DCIS. There remains uncertainty regarding the safety of BCS for multicentric disease but the outcomes of the Alliance Z11102 trial should provide the necessary evidence to support best practice [17].

This survey has provided valuable information regarding the current practice of OPBCS in the UK and will inform the design of a future large-scale study but there are limitations which require consideration. Firstly, this was a survey of current UK practice of OPBCS, and actual practice, including the numbers of procedures performed, may differ significantly from that reported. In addition, only one response per unit was requested as the survey was interested in unit level data rather than individual surgeon responses, due to it being feasibility work for a prospective cohort study. Instructions were clear but it is possible that the responses reflected the views of the completing surgeon rather than the unit as a whole which may have impacted the results. Some 58 (45%) of the 129 UK breast units completed the survey [1]. Participating units may be more engaged with OPBCS than those units who elected not to participate raising the possibility of response bias. Responses, however, were received from units of various sizes across the UK so there is no reason to believe that the findings of this work are not representative of breast units more generally. Finally, this work was largely undertaken during the exceptional circumstances of the COVID-19 pandemic. Units were asked to comment on their practice pre-COVID but COVID may have impacted both the responses received and the reported intentions of participating units to set up new services such as the offer of LPFs. Despite these limitations, the survey has provided a useful overview of the current practice and provision of OPBCS and helped to engage centres performing OPBCS as a preliminary step for a possible larger study in the future.

High-quality evidence is urgently needed to determine whether OPBCS is a better option than mastectomy (± IBR) for women not suitable for standard BCS. This survey is the first part of the ongoing ANTHEM study which will use mixed methods to inform the feasibility and design of a future large-scale study [12]. Phase 2, the prospective cohort study has recruited over 380 patients from 35 centres across the UK who have undergone either OPBCS or mastectomy (± IBR) and qualitative interviews will explore the experiences of this group. These findings will be reported in 2024.

Conclusions

The ANTHEM-NPQ has provided a valuable insight into the current practice of OPBCS in the UK. Volume displacement and replacement techniques are widely available and may improve outcomes for patients traditionally offered mastectomy. This survey is an important first step of preliminary work to determine if OPBCS offers a safe and effective alternative to mastectomy (± IBR). The ANTHEM cohort study will compare the clinical and patient-reported outcomes of OPBCS and mastectomy ± IBR to allow this to be explored further and provide high quality evidence to determine best practice and help patients and surgeons make more informed decisions about surgery.