**10. Patient choice versus treatment options**

Before the advent of oncoplastic breast surgery, limited options between WLE and simple mastectomy made surgical consultations around breast cancer treatment relatively simple. The ability to offer a wide range of surgical options does not warrant outlining the entire list to patients during their initial visit. This is particularly relevant when patients are struggling with heightened anxiety around their cancer diagnosis. There is good evidence to suggest that patients only retain a fraction of the complex discussion undertaken in a doctor's office. It requires experience and skill to navigate the complexity of information offered during the initial consultation and to gauge the patient's level of understanding.

flap for volume replacement served as the ideal option in this patient. She was well enough to be discharged after 2 days in hospital without any delay in adjuvant radiotherapy. The lateral scar remains hidden within the bra line with good functional status, low donor site morbidity, return to normal activities and high satisfaction rates with aesthetic outcomes

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(**Figure 35**).

**Figure 34.** Pre-op left breast DCIS.

**Figure 35.** Post-op extended WLE with Li-CAP volume replacement.

It is important to actively enquire if the patient is satisfied with the shape and size of her breasts at the time of diagnosis, even before instigating any discussions around OPS. In this example, a 67-year-old patient with a new screen-detected 80 mm area of DCIS in the upper outer quadrant was recommended mastectomy with sentinel node biopsy by the MDT (**Figure 33**).

The patient was keen on immediate reconstruction but raised BMI with ptotic native breast and social circumstances made implant or autologous reconstruction challenging with need for symmetrising contralateral procedure (**Figure 34**). Further discussion with the patient and option for extended WLE with SNB and immediate Li-CAP autologous dermal-adipose

**Figure 33.** Mammogram with DCIS.

flap for volume replacement served as the ideal option in this patient. She was well enough to be discharged after 2 days in hospital without any delay in adjuvant radiotherapy. The lateral scar remains hidden within the bra line with good functional status, low donor site morbidity, return to normal activities and high satisfaction rates with aesthetic outcomes (**Figure 35**).

**Figure 34.** Pre-op left breast DCIS.

**10. Patient choice versus treatment options**

(**Figure 33**).

34 Breast Cancer and Surgery

**Figure 33.** Mammogram with DCIS.

initial consultation and to gauge the patient's level of understanding.

Before the advent of oncoplastic breast surgery, limited options between WLE and simple mastectomy made surgical consultations around breast cancer treatment relatively simple. The ability to offer a wide range of surgical options does not warrant outlining the entire list to patients during their initial visit. This is particularly relevant when patients are struggling with heightened anxiety around their cancer diagnosis. There is good evidence to suggest that patients only retain a fraction of the complex discussion undertaken in a doctor's office. It requires experience and skill to navigate the complexity of information offered during the

It is important to actively enquire if the patient is satisfied with the shape and size of her breasts at the time of diagnosis, even before instigating any discussions around OPS. In this example, a 67-year-old patient with a new screen-detected 80 mm area of DCIS in the upper outer quadrant was recommended mastectomy with sentinel node biopsy by the MDT

The patient was keen on immediate reconstruction but raised BMI with ptotic native breast and social circumstances made implant or autologous reconstruction challenging with need for symmetrising contralateral procedure (**Figure 34**). Further discussion with the patient and option for extended WLE with SNB and immediate Li-CAP autologous dermal-adipose

**Figure 35.** Post-op extended WLE with Li-CAP volume replacement.

Choice of reconstruction options may be limited by patient factors like smoking status. Implant and autologous reconstruction such as DIEP are not routinely offered to women who smoke, due to unacceptably high rates of wound complications and reconstruction failure. There are many centres where implant reconstruction is routinely offered to women who smoke, but patients need to be clearly informed about the high risk of wound related complications and implant failure. Smoking causes vasoconstriction with altered bacterial flora secondary to tissue hypoxia and is believed to be responsible for the poor wound healing (**Figure 36**). This could negatively impact on younger patients due to delays in adjuvant chemotherapy.

imaging in lobular cancers, family history and discomfort from multiple biopsies and repeated mammograms; are some of the reasons for women seeking CPM. More recently, the surgical community has been criticised for 'bowing down' to patient request for double mastectomy when diagnosed with a new cancer. Some women may feel strongly about undergoing one operation, which could help reduce anxiety around repeated imaging and biopsy. It is important to carefully understand the individual patient's reasons for considering CPM. There is good evidence that CPM does not confer survival benefit and risk of contralateral breast cancer for the vast majority of patients is relatively low. Patients need to be clearly explained about the higher risk of wound related complications, delayed recovery and impact on adjuvant treatment with low benefit in terms of survival and recurrence. Despite this, if they continued to feel strongly about bilateral mastectomy with or without reconstruction, it would be

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It is important to clearly document all aspects of preoperative discussions in the clinical

There is potential for 'clinician bias' with even experienced surgeons which could alter the direction of the consultation. This could be due to preconceived ideations about patient body image, based on their appearance, educational background and socioeconomic status. Conversely, young women with large tumours are still subject to simple mastectomy without reconstruction in many hospitals around New Zealand and Australia; even in those with good clinical response to neoadjuvant chemotherapy. The rationale for this practice is based on historic concerns about potentially leaving disease behind, treatment delays or reduced effectiveness of adjuvant radiotherapy in the context of immediate reconstruction. This bias towards mastectomy genuinely stems from the sense of 'duty of care' with greater focus on the treatment and its outcome, rather than the psychological impact of mastectomy on

reasonable to offer them the option of CPM (**Figures 37** and **38**).

records due to potential medicolegal implications.

**Figure 37.** Pre-op left breast cancer.

Raised BMI is an independent risk factor for higher seroma rates, increased wound infection and anaesthetic related issues. Implant reconstruction in larger women can be difficult due to limited choices of implants to accommodate the wide chest wall dimension. The shape of the reconstructed breast is governed by the shape and size of implant and symmetrising surgery is often required to address the large and ptotic contralateral breast. The risks for wound complications are higher if this is combined with cancer surgery and could delay adjuvant therapy. In these patients, the autologous Li-CAP perforator flap or Goldilocks mastectomy (Section 2.3.1) serves as a useful and safer alternative for immediate reconstruction after mastectomy and appears to tolerate radiotherapy well. Patients need to be cautioned about prolonged seroma formation with both these options.

There has been a global increase in the incidence of contralateral prophylactic mastectomy (CPM) in the last decade and has been often labelled the 'Angeline Jolie effect'. Over the same timeframe, a well-cited Wall Street Journal article from July 2015 has resulted in increasingly number of women taking ownership for their treatment and demanding a double mastectomy [37]. Anxiety around perceived cancer recurrence, poor diagnostic yield with standard

**Figure 36.** Smoking-related complication.

imaging in lobular cancers, family history and discomfort from multiple biopsies and repeated mammograms; are some of the reasons for women seeking CPM. More recently, the surgical community has been criticised for 'bowing down' to patient request for double mastectomy when diagnosed with a new cancer. Some women may feel strongly about undergoing one operation, which could help reduce anxiety around repeated imaging and biopsy. It is important to carefully understand the individual patient's reasons for considering CPM. There is good evidence that CPM does not confer survival benefit and risk of contralateral breast cancer for the vast majority of patients is relatively low. Patients need to be clearly explained about the higher risk of wound related complications, delayed recovery and impact on adjuvant treatment with low benefit in terms of survival and recurrence. Despite this, if they continued to feel strongly about bilateral mastectomy with or without reconstruction, it would be reasonable to offer them the option of CPM (**Figures 37** and **38**).

It is important to clearly document all aspects of preoperative discussions in the clinical records due to potential medicolegal implications.

There is potential for 'clinician bias' with even experienced surgeons which could alter the direction of the consultation. This could be due to preconceived ideations about patient body image, based on their appearance, educational background and socioeconomic status. Conversely, young women with large tumours are still subject to simple mastectomy without reconstruction in many hospitals around New Zealand and Australia; even in those with good clinical response to neoadjuvant chemotherapy. The rationale for this practice is based on historic concerns about potentially leaving disease behind, treatment delays or reduced effectiveness of adjuvant radiotherapy in the context of immediate reconstruction. This bias towards mastectomy genuinely stems from the sense of 'duty of care' with greater focus on the treatment and its outcome, rather than the psychological impact of mastectomy on

**Figure 37.** Pre-op left breast cancer.

Choice of reconstruction options may be limited by patient factors like smoking status. Implant and autologous reconstruction such as DIEP are not routinely offered to women who smoke, due to unacceptably high rates of wound complications and reconstruction failure. There are many centres where implant reconstruction is routinely offered to women who smoke, but patients need to be clearly informed about the high risk of wound related complications and implant failure. Smoking causes vasoconstriction with altered bacterial flora secondary to tissue hypoxia and is believed to be responsible for the poor wound healing (**Figure 36**). This could negatively impact on younger patients due to delays in adjuvant chemotherapy.

Raised BMI is an independent risk factor for higher seroma rates, increased wound infection and anaesthetic related issues. Implant reconstruction in larger women can be difficult due to limited choices of implants to accommodate the wide chest wall dimension. The shape of the reconstructed breast is governed by the shape and size of implant and symmetrising surgery is often required to address the large and ptotic contralateral breast. The risks for wound complications are higher if this is combined with cancer surgery and could delay adjuvant therapy. In these patients, the autologous Li-CAP perforator flap or Goldilocks mastectomy (Section 2.3.1) serves as a useful and safer alternative for immediate reconstruction after mastectomy and appears to tolerate radiotherapy well. Patients need to be cautioned about

There has been a global increase in the incidence of contralateral prophylactic mastectomy (CPM) in the last decade and has been often labelled the 'Angeline Jolie effect'. Over the same timeframe, a well-cited Wall Street Journal article from July 2015 has resulted in increasingly number of women taking ownership for their treatment and demanding a double mastectomy [37]. Anxiety around perceived cancer recurrence, poor diagnostic yield with standard

prolonged seroma formation with both these options.

36 Breast Cancer and Surgery

**Figure 36.** Smoking-related complication.

Delayed LD flap with implant is a good option in patients who have had post mastectomy radiotherapy with less donor site morbidity compared to other forms of reconstruction. Any symmetrisation option for the native breast is probably best deferred for at least 6 months to allow the LD flap to settle and offers the opportunity to correct any contour defects with lipofilling at the time of the second procedure. Preoperative CT angiogram is recommended in the delayed setting to confirm patent thoracodorsal pedicle prior to lifting the LD flap. Simple bedside examination by getting the patient tense the latissimus dorsi muscle would suggest intact pedicle and formal imaging can help delineate the anatomy adequately. The CTA occasionally picks up occult lung metastasis in patients waiting for

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Breast reconstruction following mastectomy is a complex decision and requires detailed discussion with patients to ensure adequate understanding about the complexity of surgery. It is important to ensure patient compliance with post-operative protocols to help minimise woundrelated complications and potentially poor outcome from reconstruction failure. Oncoplastic breast surgeons can offer a broad range of treatment options suitable for the individual patient based on cancer biology, proposed treatment plan and patient factors, such as breast shape and density, smoking history, BMI and other medical co-morbidities. It is recommended to have a minimum of two discussions prior to any reconstructive surgery with adequate clinic time allocated to ensure detailed discussion and patient understanding about options and operative choices. Use of detailed information leaflets to suit the organisation serves as a useful adjunct to the discussion, which patients can read at home in a less stressful environment. Additional consultations offer patients the opportunities to seek clarification about the proposed operation and the surgeon can revisit the potential risks and complications to ensure informed consent.

An experienced breast care nurse familiar with various oncoplastic procedures is invaluable in helping patients with preoperative counselling and decision-making. In some patients, this process can take a few weeks and may require input from clinical psychologists. This helps confirm patient's understanding about various treatment options available, ensure decisionmaking has not been unduly influenced or coerced, and minimises the risk of 'decision-regret'

delayed reconstruction (**Figure 39**).

at a later stage.

**Figure 39.** CTA showing occult pulmonary metastasis.

**Figure 38.** Left mastectomy and CPM with implant reconstruction.

a young woman. Historic data from the National Screening Unit in the UK found that 30% of women undergoing mastectomy suffered from depression after treatment; equally 30% of women undergoing breast conservation had anxiety about recurrent cancer. The emphasis therefore should not be about avoiding a mastectomy but rather considering immediate reconstruction options in those who need mastectomy. Reverse sequencing with upfront radiotherapy in young patients is a relative new concept, which allows mastectomy with immediate autologous reconstruction, such as LD flap with implant, without compromising aesthetic outcome.

Increasing use of neoadjuvant chemotherapy and neoadjuvant endocrine therapy to downstage disease, provides adequate time to plan surgery for both patients and the treating surgeon [38, 39]. This allows time to organise genetic testing when indicated and an opportunity to improve patient health status, e.g., smoking cessation, weight loss to achieve target BMI and additional sessions with the clinical psychologists. In women with normal BMI and in whom post-operative radiotherapy is indicated, use of tissue expander as an immediate-delayed reconstruction, is advocated by the MD Anderson group and serves as a bridge to definitive reconstruction whilst preserving the mastectomy skin flap. Women are able to wake up from surgery without having to deal with the trauma of mastectomy.

The traditional approach of delaying reconstruction for several months (sometimes years) after initial cancer treatment can be detrimental to the psychosocial well-being of women struggling with their cancer diagnosis. In women with raised BMI, trying to lose weight can be a challenge and many centres would not offer delayed reconstruction unless patients achieved their target weight. There are limited options viz. DIEP for delayed reconstruction in women who have had post mastectomy radiotherapy. Some plastic surgeons would consider two-stage TE reconstruction after radiotherapy, but the results are variable due to limited skin and muscle expansion with high rates of reconstruction failure.

Delayed LD flap with implant is a good option in patients who have had post mastectomy radiotherapy with less donor site morbidity compared to other forms of reconstruction. Any symmetrisation option for the native breast is probably best deferred for at least 6 months to allow the LD flap to settle and offers the opportunity to correct any contour defects with lipofilling at the time of the second procedure. Preoperative CT angiogram is recommended in the delayed setting to confirm patent thoracodorsal pedicle prior to lifting the LD flap. Simple bedside examination by getting the patient tense the latissimus dorsi muscle would suggest intact pedicle and formal imaging can help delineate the anatomy adequately. The CTA occasionally picks up occult lung metastasis in patients waiting for delayed reconstruction (**Figure 39**).

Breast reconstruction following mastectomy is a complex decision and requires detailed discussion with patients to ensure adequate understanding about the complexity of surgery. It is important to ensure patient compliance with post-operative protocols to help minimise woundrelated complications and potentially poor outcome from reconstruction failure. Oncoplastic breast surgeons can offer a broad range of treatment options suitable for the individual patient based on cancer biology, proposed treatment plan and patient factors, such as breast shape and density, smoking history, BMI and other medical co-morbidities. It is recommended to have a minimum of two discussions prior to any reconstructive surgery with adequate clinic time allocated to ensure detailed discussion and patient understanding about options and operative choices. Use of detailed information leaflets to suit the organisation serves as a useful adjunct to the discussion, which patients can read at home in a less stressful environment. Additional consultations offer patients the opportunities to seek clarification about the proposed operation and the surgeon can revisit the potential risks and complications to ensure informed consent.

An experienced breast care nurse familiar with various oncoplastic procedures is invaluable in helping patients with preoperative counselling and decision-making. In some patients, this process can take a few weeks and may require input from clinical psychologists. This helps confirm patient's understanding about various treatment options available, ensure decisionmaking has not been unduly influenced or coerced, and minimises the risk of 'decision-regret' at a later stage.

**Figure 39.** CTA showing occult pulmonary metastasis.

a young woman. Historic data from the National Screening Unit in the UK found that 30% of women undergoing mastectomy suffered from depression after treatment; equally 30% of women undergoing breast conservation had anxiety about recurrent cancer. The emphasis therefore should not be about avoiding a mastectomy but rather considering immediate reconstruction options in those who need mastectomy. Reverse sequencing with upfront radiotherapy in young patients is a relative new concept, which allows mastectomy with immediate autologous reconstruction, such as LD flap with implant, without compromising

Increasing use of neoadjuvant chemotherapy and neoadjuvant endocrine therapy to downstage disease, provides adequate time to plan surgery for both patients and the treating surgeon [38, 39]. This allows time to organise genetic testing when indicated and an opportunity to improve patient health status, e.g., smoking cessation, weight loss to achieve target BMI and additional sessions with the clinical psychologists. In women with normal BMI and in whom post-operative radiotherapy is indicated, use of tissue expander as an immediate-delayed reconstruction, is advocated by the MD Anderson group and serves as a bridge to definitive reconstruction whilst preserving the mastectomy skin flap. Women are able to wake up from

The traditional approach of delaying reconstruction for several months (sometimes years) after initial cancer treatment can be detrimental to the psychosocial well-being of women struggling with their cancer diagnosis. In women with raised BMI, trying to lose weight can be a challenge and many centres would not offer delayed reconstruction unless patients achieved their target weight. There are limited options viz. DIEP for delayed reconstruction in women who have had post mastectomy radiotherapy. Some plastic surgeons would consider two-stage TE reconstruction after radiotherapy, but the results are variable due to limited skin

surgery without having to deal with the trauma of mastectomy.

**Figure 38.** Left mastectomy and CPM with implant reconstruction.

and muscle expansion with high rates of reconstruction failure.

aesthetic outcome.

38 Breast Cancer and Surgery

With the rapid global uptake of OPS, there remains a real danger of potentially worse patient outcome due to poor technique, improper patient selection or decision making. This is one specialty where good surgical skills are essential and inadequate training reflects on the operative outcomes with results which are glaringly obvious to both patients and clinicians.

Her continued support and expertise has made it possible to establish Oncoplastic Breast Surgery in Christchurch since 2009. The author also would like to thank all her patients for

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[1] Halsted W. The results of operations for the care of cancer of the breast performed at the Johns Hopkins hospital from June, 1889, to January, 1894. Annals of Surgery.

[2] Fisher B, Anderson S, Bryant J, et al. 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. 2002;**347**:1233-1241.

[3] Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer.

[4] Clough KS et al. Improving breast cancer surgery: A classification and quadrant per quadrant atlas for oncoplastic surgery. Annals of Surgical Oncology. 2010;**17**(5):1375-

[5] McCulley S, Macmillan RD. Planning and use of therapeutic mammoplasty—Nottingham

The New England Journal of Medicine. 2002;**347**:1227-1232. [PubMed: 12393819]

allowing use of clinical photographs and details of their diagnosis for this book chapter.

**Conflict of interest**

**Author details**

Josie Todd1,2,3,4,5\*

**References**

1894;**20**(5):497-555

[PubMed: 12393820]

1391. DOI: 10.1245/s10434-009-0792-y

approach. British Journal of Plastic Surgery. 2005;**58**:889-901

There are no conflicts of interests to declare.

2 Royal College of Surgeons of Edinburgh, UK

3 University of Otago, New Zealand

\*Address all correspondence to: josie.todd@cdhb.health.nz

1 Department of Surgery, CDHB, Christchurch, New Zealand

4 Health Disability and Ethics Commission (HDEC), New Zealand

5 Accident Compensation Corporation (ACC), New Zealand

There are well-established OPS training programmes in the UK, and post-fellowship trainees in Australasia are encouraged to undertake at least 2–3 years of additional clinical training in accredited centres. The additional training serves to up-skill their technical prowess and more importantly, learn the complex process of patient selection and the art of good communication. The rationale for oncoplastic breast surgery as an integral part of all breast cancer surgery has been eloquently detailed in a review article [40].
