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Current Practices and Barriers to the Integration of Oncoplastic Breast Surgery: A Canadian Perspective

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Despite the safety and popularity of oncoplastic surgery, there is limited data examining utilization and barriers associated with its incorporation into practice. This study examines the use of oncoplastic techniques in breast conserving surgery and determines the barriers associated with their implementation.

Methods

A 13-item survey was mailed to all registered general surgeons in Ontario, Canada. The survey assessed surgeon demographics, utilization of specific oncoplastic techniques, and perceived barriers.

Results

A total of 234 survey responses were received, representing a response rate of 32.2 % (234 of 725). Of the respondents, 166 surgeons (70.9 %) reported a practice volume of at least 25 % breast surgery. Comparison was made between general surgeons performing oncoplastic breast surgery (N = 79) and those who did not use these techniques (N = 87). Surgeon gender, years in practice, fellowship training, and access to plastic surgery were similar across groups. Both groups rated the importance of breast cosmesis similarly. General surgeons with a practice volume involving >50 % breast surgery were more likely to use oncoplastic techniques (OR 8.82, p < .001) and involve plastic surgeons in breast conserving surgery (OR 2.21, p = .02). For surgeons not performing oncoplastic surgery, a lack of training and access to plastic surgeons were identified as significant barriers. For those using oncoplastic techniques, the absence of specific billing codes was identified as a limiting factor.

Conclusions

Lack of training, access to plastic surgeons, and absence of appropriate reimbursement for these cases are significant barriers to the adoption of oncoplastic techniques.

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Acknowledgments

The authors would like to acknowledge the generous support of the North York General Hospital Exploration Fund. We thank Kimberley Fernandez for statistical support and Basma Deef, Hamdi Hussein, Muna Dahir, Marion Mohammed, and Sagal Osman for their assistance in data collection.

Disclosures

No financial or commercial disclosures from any author.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Fahima Osman MD, MPH, FRCSC.

Oncoplastic Breast Surgery in Ontario Survey

Oncoplastic Breast Surgery in Ontario Survey

Please clearly circle your chosen response.

  1. 1.

    What percentage of your referral based practice involves breast surgery?

    1. 1.

      0%

    2. 2.

      1–25%

    3. 3.

      26–50%

    4. 4.

      51–75%

    5. 5.

      ≥76%

  2. 2.

    How many years have you been in practice?

    1. 1.

      ≤5 years

    2. 2.

      6–10 years

    3. 3.

      11–15 years

    4. 4.

      16–20 years

    5. 5.

      ≥21 years

  3. 3.

    What type of hospital do you work in? (circle all that apply)

    1. 1.

      Community hospital

    2. 2.

      Academic hospital

    3. 3.

      Regional cancer centre

    4. 4.

      Other, please specify:

  4. 4.

    Do you have subspecialty fellowship training in breast surgery, surgical oncology or plastic/reconstructive surgery?

    1. 1.

      Yes

    2. 2.

      No

  5. 5.

    If YES, please indicate which type of fellowship:

    1. 1.

      Breast surgery

    2. 2.

      Surgical oncology

    3. 3.

      Plastic surgery/reconstruction based fellowship

    4. 4.

      Other, please specify:

  6. 6.

    On a scale of 1–10, how important is cosmesis in breast conserving surgery? (1 = no importance, 10 = utmost importance)

  7. 7.

    How often do you achieve good cosmesis?

    1. 1.

      Never

    2. 2.

      Rarely

    3. 3.

      Often

    4. 4.

      Always

  8. 8.

    Do you use any of the following techniques when performing breast conserving surgery? (Circle all that apply)

    1. 1.

      Skin incision planned for optimal cosmesis

    2. 2.

      Undermining of skin

    3. 3.

      Undermining of nipple areolar complex

    4. 4.

      Glandular/breast tissue reapproximation (i.e. parenchymal flaps)

    5. 5.

      Leave lumpectomy cavity open to allow for seroma formation

    6. 6.

      De-epithelialization and nipple areolar complex repositioning

    7. 7.

      Mammoplasty incision +/- superior/inferior/lateral pedicle

    8. 8.

      Bat-wing or hemi bat-wing incision

    9. 9.

      None of the above

    10. 10.

      Other, please specify:

  9. 9.

    What patient factors would lead you to offer any of the above advanced techniques?

    1. 1.

      Patient age

    2. 2.

      Patient has significant concerns regarding cosmesis

    3. 3.

      Breast size

    4. 4.

      Tumour characteristics

    5. 5.

      Other, please specify:

  10. 10.

    Do you have access to plastic surgeons in your institution?

    1. 1.

      Yes

    2. 2.

      No

  11. 11.

    Do you involve plastic surgeons in your breast conserving surgery cases?

    1. 1.

      Never

    2. 2.

      Rarely

    3. 3.

      Often

    4. 4.

      Always

    What factors would lead you to involve plastic surgeons?

  12. 12.

    To what extent do you consider the following as reasons for NOT using oncoplastic breast surgery techniques?

    Reason for not using oncoplastic technique

    Strongly disagree

    Disagree

    Agree

    Strongly Agree

    N/A

    I am unfamiliar with these techniques

         

    I am concerned about delay of adjuvant treatment

         

    I am concerned about the need for re-operation for positive margins

         

    I do not have support from plastic surgery

         

    I do not have support from radiation oncology

         

    I am concerned about increased OR time

         

    I am concerned about the lack of specific OHIP billing codes

         

    I am concerned about poor cosmesis

         

    My patients are not interested

         

    I am concerned about the rate of post-operative complications

         

    I am concerned about managing post-operative complications

         

    Other, please specify:

         
  13. 13.

    Is there anything else you would like to comment on regarding the use of oncoplastic techniques in breast surgery?

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Maxwell, J., Roberts, A., Cil, T. et al. Current Practices and Barriers to the Integration of Oncoplastic Breast Surgery: A Canadian Perspective. Ann Surg Oncol 23, 3259–3265 (2016). https://doi.org/10.1245/s10434-016-5318-9

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  • DOI: https://doi.org/10.1245/s10434-016-5318-9

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