Dear Editor:
I read with considerable concern the communication from Dr Carmichael and Dr Mokbel
in this journal on the subject ‘Evolving Trends in Breast Surgery: Oncoplastic to
Onco-Aesthetic Surgery’ [[1]]. The authors laud the use of oncoplastic breast surgery (OBS) and characterise
its further development as deserving of the designation ‘onco-aesthetics’. This suggests
a sense of justification for giving a pre-eminent role to aesthetic procedures in
the surgical treatment of breast cancer. Such a prioritisation calls for serious reconsideration
in light of treatment objectives, as current evidence indicates that the use of OBS
may have a negative impact on patient outcomes in terms of survival and morbidity.
Current data demonstrate that breast conservation treatment (BCT) is associated with
higher breast cancer-specific survival and improved local control compared with mastectomy
[[2]
[3]]. This fact legitimises the goal of expanding the eligibility for BCT and extending
its utility. The quality of cosmetic outcomes is also a factor to be considered, and
there is little objection to using reasonable methods to achieve acceptable breast
forms. However, the incremental and progressive use of OBS for the express purpose
of achieving aesthetic excellence is controversial. There are data to suggest that
patients who have undergone OBS score significantly worse than those who have undergone
standard BCT in terms of cosmetic outcomes, when assessed objectively by the software
programme BCCT.core [[4]]. This indicates that significant mobilisation during mammoplasty has implications
for both cosmesis and effective boost delivery during radiotherapy. Since conventional
surgery was also found to offer superior outcomes with respect to quality of life
and function, it has been concluded that, on the whole, the use of OBS might be disadvantageous
[[4]]. Apart from a failure to demonstrate unequivocal improvement in cosmetic outcomes,
OBS techniques are also more complex and may result in higher rates of complications;
moreover, they have not been shown to provide significant improvement in local control
[[5]]. The data indicate that larger margins with OBS may not translate to improved local
control, but may create the need for additional procedures like mammoplasty, contralateral
symmetrisation, and volume replacement with flaps [[5]]. A reductionist approach to BCT, antithetic to the philosophy that informs OBS,
involves neoadjuvant systemic treatment where appropriate and demands accuracy in
dissection for lower tissue resection volumes, which could decrease the need for excessively
wide excisions and contralateral symmetrisations without compromising cosmesis and
local control.
The adaptation of plastic surgery techniques to BCT has undoubtedly led to improvements
in cosmetic outcomes. This has provided the impetus for ongoing development, resulting
in an exponential increase in the range of OBS techniques. However, the routine and
incremental use of OBS techniques is expansive and involves invasive procedures to
a greater degree. This may be contrary to the basic tenets of medical therapy, which
is founded on the principle of non-maleficence. Perhaps it is time to re-examine our
objectives for the surgical treatment of breast cancer, and whether the current trend
of oncoplastic to onco-aesthetic surgery stands up to the scrutiny of primum non nocere.
In over-emphasising aesthetics in breast surgical oncology, we may be subjecting our
patients to the disservice of overtreatment.