ABCR  Vol.8 No.1 , January 2019
Combined Patients and Medical Related Cosmetic Breast Cancer Outcomes—A Preferred Approach to Outcomes Assessment
Abstract: Introduction: Reducing positive margins and need for re-excision yet maintaining cosmesis is key in breast cancer surgery. This study describes the evaluation of early outcomes of a combined cosmetic assessment programme following breast conservation surgery (BCS). Methods: An ethically approved prospective study was conducted at Letterkenny University Hospital and a 15-month timeframe was chosen. All consecutive patients undergoing conservative breast surgery with complete local excision, from July 2015 to October 2016, were entered into the study. Patients undergoing mastectomy and reconstruction with either implant or autologous tissue were not included. 41 patients undergoing BCS were analysed. Objective and subjective cosmetic evaluations were carried out. Assessments used were the Breast Cancer Conservative Treatmentcosmetic results [BCCT.core 2.0] Software, a panel of 4 experts in breast surgery and the Breast Cancer Treatment Outcome Scale (BCTOS). Demographic and pathological data, breast excision weight, % breast volume excised (BVE), margin positivity, complications and re-excision were documented. Data was expressed as mean and standard deviation for normally distributed data and medians and inter quartile range for non-normal data. Scores were also dichotomised to excellent/good and fair/poor and results were analysed. Results: 41 patients mean age is 55 ± 13 years. Mean breast volume was 768.3 cm3 ± 440; BVE weighed 78.6g ± 42.6 (18.9 - 214.4) and %BVE 11.3% ± 5.2% (5.1 - 23.3). Re-excision rate was 2/41 (4.9%) all for positive margins. 0/41 infections or haematomas occurred. Cosmetic status of 10 - 14 days post surgery was excellent or good by BCCT.core Software 78%, Expert panel 82.9%, BCTOS scale (92.7%), and fair or poor in 22%, 17.1% and 7.3% respectively. Conclusion: This study successfully evaluated objective and subjective cosmetic related outcomes following breast conserving surgery, incorporating both patient and surgeon in these assessments. The encouraging results show that despite low re-excision rates, acceptable cosmetic outcomes were achieved.
Cite this paper: Sugrue, M. , Johnston, A. , Degnim, A. , Rubio, I. , den Tol, M. , Djohan, R. , Valentine, M. and Gregor, G. (2019) Combined Patients and Medical Related Cosmetic Breast Cancer Outcomes—A Preferred Approach to Outcomes Assessment. Advances in Breast Cancer Research, 8, 31-44. doi: 10.4236/abcr.2019.81003.

[1]   Howell, D., Molloy, S., Wilkinson, K., et al. (2015) Patient-Reported Outcomes in Routine Cancer Clinical Practice: A Scoping Review of Use, Impact on Health Outcomes, and Implementation Factors. Annals of Oncology, 26, 1846-1858.

[2]   Basch, E. (2017) The Rise of Patient-Reported Outcomes in Oncology. In ASCO Annual Meeting.

[3]   Bride, M.B., Neal, L., Dilaveri, C.A., et al. (2013) Factors Associated with Surgical Decision Making in Women with Early-Stage Breast Cancer: A Literature Review. Journal of Women’s Health, 22, 236-242.

[4]   Fisher, B., Anderson, S., Bryant, J., et al. (2002) Twenty-Year Follow-Up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer. The New England Journal of Medicine, 347, 1233-1241.

[5]   Veronesi, U., Cascinelli, N., Mariani, L., et al. (2002) Twenty-Year Follow-Up of a Randomized Study Comparing Breast-Conserving Surgery with Radical Mastectomy for Early Breast Cancer. The New England Journal of Medicine, 347, 1227-1232.

[6]   Livingston, E.H. and Li, H.C. (2017) Breast Cancer Surgery: Less Is More. JAMA, 318, 909-911.

[7]   Agarwal, S., Pappas, L., Neumayer, L., et al. (2014) Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer. JAMA Surgery, 149, 267-274.

[8]   Krekel, N., Zonderhuis, B., Muller, S., et al. (2011) Excessive Resections in Breast-Conserving Surgery: A Retrospective Multicentre Study. The Breast Journal, 17, 602-609.

[9]   Haloua, M.H., Volders, J.H., Krekel, N.M., et al. (2016) A Nationwide Pathology Study on Surgical Margins and Excision Volumes after Breast-Conserving Surgery: There Is Still Much to Be Gained. Breast, 25, 14-21.

[10]   Hayashi, N., Tsunoda, H., Abe, E., et al. (2012) Ultrasonography-and/or Mammography-Guided Breast Conserving Surgery for Ductal Carcinoma in Situ of the Breast: Experience with 87 Lesions. Breast Cancer, 19, 131-137.

[11]   Unzeitig, A., Kobbermann, A., Xie, X.J., et al. (2012) Influence of Surgical Technique on Mastectomy and Re-Excision Rates in Breast-Conserving Therapy for Cancer. International Journal of Surgical Oncology, 2012, Article ID: 725151.

[12]   Saolta University Health Care Group. (2015) Symptomatic Breast Service Annual Report. Health Service Executive.

[13]   Beecher, S.M., O’Leary, D.P., McLaughlin, R., et al. (2016) Influence of Complications Following Immediate Breast Reconstruction on Breast Cancer Recurrence Rates. British Journal of Surgery, 103, 391-398.

[14]   Racz, J.M., Hong, N.L. and Latosinsky, S. (2015) In Search of a Gold Standard Scoring System for the Subjective Evaluation of Cosmetic Outcomes Following Breast-Conserving Therapy. The Breast Journal, 21, 345-351.

[15]   Landercasper, J., Attai, D., Atisha, D., et al. (2015) Toolbox to Reduce Lumpectomy Reoperations and Improve Cosmetic Outcome in Breast Cancer Patients: The American Society of Breast Surgeons Consensus Conference. Annals of Surgical Oncology, 22, 3174-3183.

[16]   Pukancsik, D., Kelemen, P., újhelyi, M., et al. (2017) Objective Decision Making between Conventional and Oncoplastic Breast-Conserving Surgery or Mastectomy: An Aesthetic and Functional Prospective Cohort Study. EJSO, 43, 303-310.

[17]   Merie, E., Browne, L., Cardoso, J., et al. (2017) Proposal for a Gold Standard for Cosmetic Evaluation after Breast Conserving Therapy: Results from the St George and Wollongong Breast Boost Trial. Journal of Medical Imaging and Radiation Oncology, 61, 819-825.

[18]   Oliveira, H.P., Cardoso, J.S., Magalhaes, A., et al. (2013) Methods for the Aesthetic Evaluation of Breast Cancer Conservation Treatment: A Technological Review. Current Medical Imaging Reviews, 9, 32-46.

[19]   Shaikh, T., Narra, V., Goyal, S., et al. (2013) Lumpectomy Closure Technique Does Not Affect Dosimetry in Patients Undergoing External-Beam-Based Accelerated Partial Breast Irradiation. Annals of Surgical Oncology, 20, 1323-1328.

[20]   Ting, G., McGowan, K., Cooley, G., et al. (2015) The Role of Ultrasound Guided Core Biopsy of Axillary Nodes in Predicting Macrometastases and Avoiding Overtreatment outside ACOSOG Z0011 Parameters. Breast, 24, 57-61.

[21]   Cardoso, M.J., Cardoso, J., Amaral, N., et al. (2007) Turning Subjective into Objective: The BCCT.core Software for Evaluation of Cosmetic Results in Breast Cancer Conservative Treatment. Breast, 16, 456-461.

[22]   Harris, J.R., Levene, M.B., Svensson, G., et al. (1979) Analysis of Cosmetic Results Following Primary Radiation Therapy for Stages I and II Carcinoma of the Breast. International Journal of Radiation Oncology, Biology, Physics, 5, 257-261.

[23]   Stanton, A.L., Krishnan, L. and Collins, C.A. (2001) Form or Function? Part 1. Subjective Cosmetic and Functional Correlates of Quality of Life in Women Treated with Breast-Conserving Surgical Procedures and Radiotherapy. Cancer, 91, 2273-2281.<2273::AID-CNCR1258>3.0.CO;2-1

[24]   Heil, J., Dahlkamp, J., Golatta, M., et al. (2011) Aesthetics in Breast Conserving Therapy: Do Objectively Measured Results Match Patients’ Evaluations? Annals of Surgical Oncology, 18, 134-138.

[25]   Shanley, E., Johnston, A., Hillick, D., Ng, K.C. and Sugrue, M. (2018) Digital Breast Volume Estimation (DBVE)—A New Technique. The British Journal of Radiology, 91.

[26]   Boughey, J.C., Hieken, T.J., Jakub, J.W., et al. (2014) Impact of Analysis of Frozen-Section Margin on Reoperation Rates in Women Undergoing Lumpectomy for Breast Cancer: Evaluation of the National Surgical Quality Improvement Program Data. Surgery, 156, 190-197.

[27]   Mallucci, P. and Branford, O.A. (2012) Concepts in Aesthetic Breast Dimensions: Analysis of the Ideal Breast. Journal of Plastic, Reconstructive & Aesthetic Surgery, 65, 8-16.

[28]   Ojala, K., Meretoja, T.J. and Leidenius, M.H. (2017) Aesthetic and Functional Outcome after Breast Conserving Surgery—Comparison between Conventional and Oncoplastic Resection. European Journal of Surgical Oncology, 43, 658-664.

[29]   Vos, E.L., Koning, A.H., Obdeijn, I.M., et al. (2015) Preoperative Prediction of Cosmetic Results in Breast Conserving Surgery. Journal of Surgical Oncology, 111, 178-184.

[30]   Nano, M.T., Gill, P.G., Kollias, J., Bochner, M.A., et al. (2005) Psychological Impact and Cosmetic Outcome of Surgical Breast Cancer Strategies. ANZ Journal of Surgery, 75, 940-947.

[31]   Volders, J.H., Negenborn, V.L., Haloua, M.H., et al. (2017) Cosmetic Outcome and Quality of Life Are Inextricably Linked in Breast-Conserving Therapy. Journal of Surgical Oncology, 115, 941-948.

[32]   Hennigs, A., Hartmann, B. and Rauch, G. (2015) Long-Term Objective Esthetic Outcome after Breast-Conserving Therapy. Breast Cancer Research and Treatment, 153, 345-351.

[33]   Hennigs, A., Biehl, H., Rauch, G., et al. (2016) Change of Patient-Reported Aesthetic Outcome over Time and Identification of Factors Characterizing Poor Aesthetic Outcome after Breast-Conserving Therapy: Long-Term Results of a Prospective Cohort Study. Annals of Surgical Oncology, 23, 1744-1751.

[34]   Kopec, J.A., Colangelo, L.H., Land, S.R., et al. (2013) Relationship between Arm Morbidity and Patient-Reported Outcomes Following Surgery in Women with Node-Negative Breast Cancer: NSABP Protocol B-32. Journal of Surgical Oncology, 11, 22.

[35]   Patterson, M.P., Pezner, R.D., Hill, L.R., et al. (1985) Patient Self-Evaluation of Cosmetic Outcome of Breast-Preserving Cancer Treatment. International Journal of Radiation Oncology, Biology, Physics, 11, 1849-5182.

[36]   Key, S., Miglierini, P., Dupré, P.F., et al. (2017) Cosmetic Outcome and Chronic Breast Toxicity after Intraoperative Radiation Therapy (IORT) as a Single Modality or as a Boost Using the Intrabeam® Device: A Prospective Study. Annals of Surgical Oncology, 24, 2547-2555.

[37]   Taylor, M.E., Perez, C.A., Halverson, K.J., et al. (1995) Factors Influencing Cosmetic Results after Conservation Therapy for Breast Cancer. International Journal of Radiation Oncology, Biology, Physics, 31, 753-764.

[38]   Yip, J.M., Mouratova, N., Jeffery, R.M., et al. (2012) Accurate Assessment of Breast Volume: A Study Comparing the Volumetric Gold Standard (Direct Water Displacement Measurement of Mastectomy Specimen) with a 3D Laser Scanning Technique. Annals of Plastic Surgery, 68, 135-141.

[39]   Kayar, R., Civelek, S., Cobanoglu, M., et al. (2011) Five Methods of Breast Volume Measurement: A Comparative Study of Measurements of Specimen Volume in 30 Mastectomy Cases. Breast Cancer: Basic and Clinical Research, 5, 43-52.

[40]   Yu, T., Eom, K.Y., Jang, N.Y., et al. (2016) Objective Measurement of Cosmetic Outcomes of Breast Conserving Therapy Using BCCT.core. Cancer Research and Treatment, 48, 491-498.

[41]   Dahlback, C., Ullmark, J.H., Rehn, M., et al. (2017) Aesthetic Result after Breast-Conserving Therapy Is Associated with Quality of Life Several Years after Treatment. Swedish Women Evaluated with BCCT.core and BREAST-QTM. Breast Cancer Research and Treatment, 23, 1-9.

[42]   Cardoso, M.J., Cardoso, J.S., Vrieling, C., et al. (2012) Recommendations for the Aesthetic Evaluation of Breast Cancer Conservative Treatment. Breast Cancer Research and Treatment, 135, 629-637.

[43]   Nohara, Y., Hanamura, N., Zaha, H., et al. (2015) Cosmetic Evaluation Methods Adapted to Asian Patients after Breast-Conserving Surgery and Examination of the Necessarily Elements for Cosmetic Evaluation. Journal of Breast Cancer, 18, 80-86.

[44]   Lee, M., Patel, M., Cresswell, A.B., et al. (2007) Body Image Score Following Anterior and Lateral Approaches to Wide Local Excision for Early Breast Cancer. The Breast Journal, 13, 238-242.

[45]   Brouwers, P., Van Werkhoven, E., Van Loon, J., et al. (2016) PO-0674: Factors Influencing Patient Reported Cosmetic Outcome: Results of the Young Boost Trial. Radiotherapy and Oncology, 119, S314-S315.

[46]   Vrieling, C., Collette, L., Fourquet, A., et al. (2000) The Influence of Patient, Tumor and Treatment Factors on the Cosmetic Results after Breast-Conserving Therapy in the EORTC “Boost vs. No Boost” Trial. Radiotherapy and Oncology, 55, 219-232.

[47]   Pusic, A.L., Klassen, A.F., Scott, A.M., et al. (2009) Development of a New Patient-Reported Outcome Measure for Breast Surgery: The BREAST-Q. Plastic and Reconstructive Surgery, 124, 345-353.

[48]   Sugrue, R., MacGregor, G., Sugrue, M., et al. (2013) An Evaluation of Patient Reported Outcomes Following Breast Reconstruction Utilizing Breast Q. Breast, 22, 158-161.

[49]   Pezner, R.D., Lipsett, J.A., Vora, N.L., et al. (1985) Limited Usefulness of Observer-Based Cosmesis Scales Employed to Evaluate Patients Treated Conservatively for Breast Cancer. International Journal of Radiation Oncology, Biology, Physics, 11, 1117-1119.

[50]   Fortin, A.J., Cheang, M. and Latosinsky, S. (2006) Cosmetic Outcomes Following Breast Conservation Therapy: In Search of a Reliable Scale. Breast Cancer Research and Treatment, 100, 65-70.

[51]   Kim, K.D., Kim, Z., Kuk, J.C., et al. (2016) Long-Term Results of Oncoplastic Breast Surgery with Latissimus Dorsi Flap Reconstruction: A Pilot Study of the Objective Cosmetic Results and Patient Reported Outcome. Annals of Surgical Treatment and Research, 90, 117-123.

[52]   Velikova, G., Booth, L., Smith, A.B., et al. (2004) Measuring Quality of Life in Routine Oncology Practice Improves Communication and Patient Well-Being: A Randomized Controlled Trial. Journal of Clinical Oncology, 22, 714-724.