**2. Surgical management of early-stage breast cancer**

Until the seventies, mutilating procedures in the breast and axilla, intended for disease eradication, were the only available surgical options in breast cancer treatment, irrespective of the stage of the disease. Better insights into breast cancer biology, as well as a better understanding of the natural course of the disease, have contributed to substantial changes in surgical management over the last five decades. Clinical trials, initiated by Veronesi and Fisher [5–7], have demonstrated that breast conservative surgery, accompanied by adjuvant breast irradiation, is not an inferior option for the early-stage (T1-T2) breast cancer treatment. Moreover, the survival outcomes in several, more recent, population-based studies [8–13] favour a conservative approach (**Table 1**).

As no benefit has not ever been associated with the more extensive procedures, breast surgery has been de-escalated to the more conservative options. Several synonyms for breast conservative surgery (BCS) are present in the literature: partial mastectomy, quadrantectomy, segmentectomy and lumpectomy. Although there are slight differences among the original definitions, nowadays the term represents


#### **Table 1.**

*Overall survival (OS) and/or breast cancer specific survival (BCSS) in relation to surgical treatment: Mastectomy (Mx) vs. breast conservative surgery (BCS).*

#### *Oncoplastic Breast Conservation: A Standard of Care in Modern Breast Cancer Surgical… DOI: http://dx.doi.org/10.5772/intechopen.108944*

a breast tumour resection with appropriate histological margins, that is, 'no ink on tumour' for invasive breast cancer and a minimum of 2 mm of benign breast tissue surrounding the *in situ* disease [14, 15]. The goal of this treatment de-escalation strategy is QoL improvement, related to breast preservation. Nevertheless, the conventional, ablative-only approach in BCS has several limitations considering breast shape and symmetry, that is, breast aesthetics, and may impact QoL just opposite than anticipated [16].

The breast resection volume and the lesion location within the breast are major determinants of the aesthetic outcome following conventional BCS. Even in the early stage of the disease (T1-T2), a 30% risk of breast deformity is reported in the literature. Resection volume over 15–20% of breast volume in outer quadrants and over 10% in medial or central quadrants, without partial breast reconstruction, may already result in some degree of breast deformity [17, 18]. In addition, natural (preoperative) breast shape, degree of ptosis and breast glandular density impact the aesthetic outcome as well. According to available literature data [19], four degrees of breast deformity have been reported following BCS, from a mild NAC retraction to the severe distortion of the entire breast.

The oncoplastic approach emerged at the end of the last century with intention of overcoming the limitations of conventional BCS. Following oncoplastic procedures, breast shape and symmetry remain preserved, although the breast volume may be reduced. Moreover, breast aesthetics can be improved with this type of cancer surgery.

The term 'oncoplastic' was first mentioned by German surgeon Audretsch in 1993 [20]. Merged from the Greek words 'onco' (tumour) and 'plastic' (shaping), it signifies reshaping the breast after the tumour resection. Although the primary goal remains oncological safe cancer resection, the enhanced aesthetic outcomes, achieved within this approach, contribute to the improvements of the QoL among the survivors. The concept was therefore easily accepted worldwide and is further developing into a new surgical discipline.

Superior aesthetic outcomes are not the only advantage of the oncoplastic approach. In a meta-analysis of 8659 patients from 61 studies [16], specimen weight, re-excision rate, local recurrence rate and patient satisfaction were compared between conventional and oncoplastic BCS. All analysed endpoints favour the oncoplastic approach, indicating that higher rates of BCS with lower re-excision rates can be achieved in addition to lower local recurrence rates and higher patient satisfaction. It is interesting to consider that the same endpoints are proposed by the EUSOMA working group [21] for quality indicators (QIs) in the early-stage breast cancer surgical management evaluation. Accordingly, higher rates of breast conservation for low volume *in situ* and invasive breast disease, as well as lower rates of re-excision following BCS, suggest a higher quality of surgical management. In other words, the mastectomy rate of over 30%, in this subgroup of patients, indicates the poor quality of surgical management. Additional arguments that further support the latest observation are available in the scientific literature as well. Potter reports significantly higher rates of complications, re-operations and re-admissions to hospital in the oncoplastic mastectomy group as compared to oncoplastic breast conservation, in patients with tumour size less than 3 cm [22]. In Chands' QoL analysis, all aspects of the validated questionnaire (breast appearance, physical, emotional and sexual well-being) were better in the oncoplastic BCS group, when compared to any type of postmastectomy reconstruction [23]. Finally, in the Dutch cost-utility study, oncoplastic BCS is reported as more cost-effective than mastectomy followed by implantbased or autologous breast reconstruction [24].

#### **Figure 1.**

*Surgical options in early-stage breast cancer treatment. OP-BCS = oncoplastic breast conservative surgery, OP-Mx = oncoplastic mastectomy.*

Considering all the above-mentioned arguments favouring oncoplastic BCS, the author believes that mastectomy should no longer be offered as a comparable treatment option for a low-volume breast disease unless there is a strong oncologic contraindication for breast conservation (**Figure 1**).

With all available oncoplastic techniques, the technical feasibility of surgery should not represent an issue in this stage of the disease. Moreover, the oncoplastic approach offers the opportunity for breast preservation even in selected patients with locally advanced disease [25].
