[4 MIN READ]

In this article:

• Oncoplastic breast-conserving surgery uses plastic surgery techniques during breast cancer surgery to preserve the breast’s appearance while removing the cancer cells.

• Breast-conserving surgery can be an effective treatment option for women with early-stage breast cancer.

• Using oncoplastic surgery techniques gives more choices to women who might not be good candidates for breast-conserving surgery otherwise.

For many women diagnosed with early-stage breast cancer, breast-conserving surgery (BCS) is an effective cancer treatment that allows them to keep a large portion of their breast tissue intact.

BCS is also known as lumpectomy or partial mastectomy. During surgery, abnormal breast tissue, along with a margin of healthy tissue, is removed. Part of the chest wall lining may also be removed depending on the location of the cancer.

At Swedish, surgeons also employ oncoplastic breast-conserving surgery (OBCS) to give women with early-stage breast cancer another option to get their best result. This advanced technique reshapes the breast and maintains its appearance after removing the cancer cells. Research shows OBCS leads to fewer surgical site complications and improves the way the breast looks after surgery.

“Oncoplastic surgery uses plastic surgery techniques to facilitate lumpectomy. The techniques used can make lumpectomy an option for women who may not otherwise have been good candidates for breast conservation,” says Swedish breast surgeon Angelena Crown, M.D.

Dr. Crown is an OBCS specialist, with extensive training in oncoplastic surgery and clinical expertise in benign and malignant breast diseases. We talked with her about OBCS and how this innovative approach expands the choices available to women with breast cancer.

Q+A with Dr. Angelena Crown: oncoplastic breast-conserving surgery

Q. Who is a candidate for OBCS?

A. We use comprehensive breast imaging and a clinical breast exam to evaluate whether a woman is eligible for OBCS. Because our imaging technology has improved so much, we can catch many breast cancers at their earliest stages. In fact, 25% of breast cancer diagnoses are Stage 0! 

Although there are certainly nuances to determining whether a patient is a candidate for breast conservation, common criteria include breast to tumor ratio, whether the patient is able and willing to receive radiation therapy and if an acceptable aesthetic outcome can be achieved with the lumpectomy based on tumor size and location.

We also consider genetic testing in many women. About 5% to 10% of breast cancer cases result from genetic mutations passed on by a parent. Women who are genetically predisposed to breast cancer may choose OBCS. However, finding out that they are at increased risk of additional breast cancers in the future may prompt some to choose surgical removal of both breasts (bilateral mastectomy) for risk reduction.

Q. Does OBCS change the shape of the breasts? Will patients need additional reconstructive surgery?

A. This really depends on the size and location of the tumor and the size of the breast. With a small tumor in a large breast, removing a minimal amount of breast tissue may not be noticeable. However, in most cases, it is not that simple.

I think the best way to picture this is to think of the breast and breast skin as a pillow in a pillowcase. If you remove some of the pillow stuffing without tailoring the pillowcase, the pillow will appear deflated. The same can be true with the breast after a lumpectomy. We often perform tissue rearrangements to help fill the cavity that the lumpectomy creates, but slight deflation can still occur.

One way to improve the way the breasts look after surgery is to work with plastic surgeons who offer advanced oncoplastic techniques such as breast lift (mastopexy) and breast reduction (reduction mammoplasty). These procedures reshape the skin envelope and rearrange normal breast tissue to give a more lifted and full appearance to the breast. It’s like removing some of the stuffing from the pillow, then fluffing up the remaining contents, and trimming the pillowcase to give it a fuller appearance.

Q. What can women who choose OBCS expect post-operatively? What limitations may a woman encounter during recovery?

A. Recovery after OBCS is typically 1-2 weeks. Most women find that the recovery was much easier than they expected. We ask that they limit heavy lifting in the early recovery period, but they can shower and go about most of their daily activities immediately. Recovery after more advanced oncoplastic techniques can be longer.

Q. Is OBCS a viable option for pregnant women or women trying to conceive? 

A. It depends on several factors, including the stage of pregnancy. Lumpectomy is routinely paired with radiation and radiation is contraindicated during pregnancy.

We usually prefer to start radiation within eight weeks of a lumpectomy. Because the delay is unacceptably long if lumpectomy is performed early in pregnancy, we generally recommend mastectomy instead of OBCS in that setting.

If a woman is further along in pregnancy, a lumpectomy can be performed during pregnancy and the radiation can be delayed until after delivery. This approach can provide excellent outcomes for both the patient and the baby. 

Because chemotherapy is safe during pregnancy, starting in the second trimester, pregnant women may receive chemotherapy during pregnancy and then have surgery after delivery. In this situation, a lumpectomy is often an option because the radiation would be able to start on time.

Additionally, recent studies have shown that chemotherapy can shrink tumors that would have required mastectomy into tumors that can be successfully treated with lumpectomy and radiation 50% of the time.

We typically recommend that women wait two years to get pregnant after being treated for breast cancer. We like for women with estrogen receptor-positive breast cancers to receive anti-estrogen therapy and avoid pregnancy while they are at the highest risk for recurrence.

Breast cancer treatment is associated with infertility. This is because we ask women to delay pregnancy, which subjects them to the natural decline in fertility that comes with increasing age. This is compounded by the fact that some treatments, such as chemotherapy, may directly impact their ovarian reserve (the number and quality of eggs).

Concerns about fertility are extremely important to us when a woman develops breast cancer. We immediately refer women who think they may want to have biological children in the future to consult with a reproductive endocrinologist to discuss fertility preservation options. Many studies show that it is safe to perform fertility preservation (such as egg freezing) during a breast cancer diagnosis. We completely support women pursuing these options.

Q. What is the next step of a woman’s breast cancer journey after fully recovering from OBCS? What does the follow-up treatment plan look like?

A. While a woman recovers from a lumpectomy, our pathologists evaluate the cancer cells from surgery. This helps us determine what additional treatments to recommend.

We consider radiation an integral component of breast-conserving therapy. Long-term follow-up of multiple clinical trials shows that lumpectomy plus radiation has the same survival rate as mastectomy. More recent studies have shown that the risk of cancer coming back in the breast is the same. Without radiation, the risk of recurrence after lumpectomy is much higher.

In the case of tumors that express estrogen and progesterone, we recommend anti-estrogen therapy, such as tamoxifen or an aromatase inhibitor. For women who have tumors that express a growth factor receptor called HER2 we recommend treatment with chemotherapy and targeted anti-HER2 therapy which blocks the function of the HER2 receptor.

Q. Can you discuss the differences between BCS and OBCS? How should a woman decide which procedure is best for her?

A. The standard definition of oncoplastic breast surgery is the use of plastic surgery techniques to facilitate the removal of the tumor. I see oncoplastic surgery as a way of thinking about lumpectomy.

To me, every lumpectomy is an oncoplastic surgery. I spend a lot of time thinking about the best way to remove a tumor – from what incision to use, how to fill the cavity to restore the shape of the breast, and how to optimize the skin closure to give a woman the best possible oncologic and aesthetic result. In addition to optimizing the appearance of the breast after surgery, recent studies have indicated that oncoplastic surgery can help reduce the risk of positive margins which may require a second surgery to obtain clear margins, and that the rate of surgical complications with OBCS may be lower than with BCS.

I discuss this approach to lumpectomy as well as the more advanced oncoplastic approaches with all patients. I refer women who indicate any interest in the more advanced oncoplastic techniques to our plastic surgeons to discuss the options further. Looking at pictures can often be very helpful to women as they weigh these decisions.

I think it's essential for women to hear all of their options and the pros and cons of each one so that they can make the right decision for themselves.

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This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.