We explored the impact of the relative volume of a tumor versus the entire breast on outcomes in patients undergoing breast conservation therapy (BCT) versus mastectomy and reconstruction (M + R). We hypothesized that there would be a threshold tumor:breast ratio (TBR) below which patient-reported outcomes (PRO) would favor BCT and above which would favor M + R.
We conducted a prospective cohort study of patients with ductal carcinoma in situ (DCIS) or invasive breast cancers undergoing BCT or M + R. A prerequisite for inclusion, analysis of tumor and breast volumes was conducted from three-dimensional magnetic resonance imaging reconstructions to calculate the TBR. Three-dimensional photography was utilized to calculate pre- and postoperative volumes and assess symmetry. Oncologic, surgical, and patient-reported outcome data were obtained from relevant BREAST-Q modules administered pre- and postoperatively.
The BCT cohort had significantly smaller tumor volumes (p = 0.001) and lower TBRs (p = 0.001) than patients undergoing M + R overall. The M + R group, however, comprised a broader range of TBRs, characterized at lower values by patients opting for contralateral prophylactic mastectomy. Postoperative satisfaction with breasts, psychosocial, and sexual well-being scores were significantly higher in the BCT cohort, while physical well-being significantly favored the M + R cohort 480.2 ± 286.3 and 453.1 ± 392.7 days later, respectively.
Relative to BCT, M + R was used to manage a broad range of TBRs. The relative importance of oncologic and surgical risk reduction, symmetry, and number of procedures can vary considerably and may limit the utility of TBR as a guide for deciding between BCT and M + R.
Clinical Trial StatementThis study was registered with clinicaltrials.gov as “A Prospective Trial to Assess Tumor:Breast Ratio and Patient Satisfaction Following Lumpectomy Versus Mastectomy With Reconstruction”, Identifier: NCT02216136.
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Arriagada R, Le MG, Rochard F, Contesso G (1996) Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group. J Clin Oncol 14(5):1558–1564
Blichert-Toft M, Rose C, Andersen JA, Overgaard M, Axelsson CK, Andersen KW, Mouridsen HT (1992) Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis. Danish Breast Cancer Cooperative Group. J Natl Cancer Inst Monogr 11:19–25
Morrow M, Harris JR, Schnitt SJ (2012) Surgical margins in lumpectomy for breast cancer–bigger is not better. N Engl J Med 367(1):79–82. https://doi.org/10.1056/NEJMsb1202521
Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N (2002) Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 347(16):1233–1241. https://doi.org/10.1056/NEJMoa022152
Poggi MM, Danforth DN, Sciuto LC, Smith SL, Steinberg SM, Liewehr DJ, Menard C, Lippman ME, Lichter AS, Altemus RM (2003) Eighteen-year results in the treatment of early breast carcinoma with mastectomy versus breast conservation therapy: the National Cancer Institute Randomized Trial. Cancer 98(4):697–702. https://doi.org/10.1002/cncr.11580
van Dongen JA, Voogd AC, Fentiman IS, Legrand C, Sylvester RJ, Tong D, van der Schueren E, Helle PA, van Zijl K, Bartelink H (2000) Long-term results of a randomized trial comparing breast-conserving therapy with mastectomy: European Organization for Research and Treatment of Cancer 10801 trial. J Natl Cancer Inst 92(14):1143–1150
Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, Aguilar M, Marubini E (2002) Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 347(16):1227–1232. https://doi.org/10.1056/NEJMoa020989
Al-Ghazal SK, Fallowfield L, Blamey RW (2000) Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction. Eur J Cancer 36(15):1938–1943
Howes BH, Watson DI, Xu C, Fosh B, Canepa M, Dean NR (2016) Quality of life following total mastectomy with and without reconstruction versus breast-conserving surgery for breast cancer: a case-controlled cohort study. J Plast Reconstr Aesthet Surg 69(9):1184–1191. https://doi.org/10.1016/j.bjps.2016.06.004
Atisha DM, Rushing CN, Samsa GP, Locklear TD, Cox CE, Shelley Hwang E, Zenn MR, Pusic AL, Abernethy AP (2015) A national snapshot of satisfaction with breast cancer procedures. Ann Surg Oncol 22(2):361–369. https://doi.org/10.1245/s10434-014-4246-9
Exner R, Krois W, Mittlbock M, Dubsky P, Jakesz R, Gnant M, Fitzal F (2012) Objectively measured breast symmetry has no influence on quality of life in breast cancer patients. Eur J Surg Oncol 38(2):130–136. https://doi.org/10.1016/j.ejso.2011.10.012
Cordeiro PG (2008) Breast reconstruction after surgery for breast cancer. N Engl J Med 359(15):1590–1601. https://doi.org/10.1056/NEJMct0802899
Macadam SA, Zhong T, Weichman K, Papsdorf M, Lennox PA, Hazen A, Matros E, Disa J, Mehrara B, Pusic AL (2016) Quality of life and patient-reported outcomes in breast cancer survivors: a multicenter comparison of four abdominally based autologous reconstruction methods. Plast Reconstr Surg 137(3):758–771. https://doi.org/10.1097/01.prs.0000479932.11170.8f
Zhong T, McCarthy C, Min S, Zhang J, Beber B, Pusic AL, Hofer SO (2012) Patient satisfaction and health-related quality of life after autologous tissue breast reconstruction: a prospective analysis of early postoperative outcomes. Cancer 118(6):1701–1709. https://doi.org/10.1002/cncr.26417
Yoon AP, Qi J, Brown DL, Kim HM, Hamill JB, Erdmann-Sager J, Pusic AL, Wilkins EG (2017) Outcomes of immediate versus delayed breast reconstruction: results of a multicenter prospective study. Breast 37:72–79. https://doi.org/10.1016/j.breast.2017.10.009
Jagsi R, Griffith KA, Kurian AW, Morrow M, Hamilton AS, Graff JJ, Katz SJ, Hawley ST (2015) Concerns about cancer risk and experiences with genetic testing in a diverse population of patients with breast cancer. J Clin Oncol 33(14):1584–1591. https://doi.org/10.1200/JCO.2014.58.5885
Ashfaq A, McGhan LJ, Pockaj BA, Gray RJ, Bagaria SP, McLaughlin SA, Casey WJ 3rd, Rebecca AM, Kreymerman P, Wasif N (2014) Impact of breast reconstruction on the decision to undergo contralateral prophylactic mastectomy. Ann Surg Oncol 21(9):2934–2940. https://doi.org/10.1245/s10434-014-3712-8
Zork NM, Komenaka IK, Pennington RE Jr, Bowling MW, Norton LE, Clare SE, Goulet RJ Jr (2008) The effect of dedicated breast surgeons on the short-term outcomes in breast cancer. Ann Surg 248(2):280–285. https://doi.org/10.1097/SLA.0b013e3181784647
Waljee JF, Hu ES, Newman LA, Alderman AK (2008) Correlates of patient satisfaction and provider trust after breast-conserving surgery. Cancer 112(8):1679–1687. https://doi.org/10.1002/cncr.23351
Waljee JF, Hu ES, Newman LA, Alderman AK (2008) Predictors of re-excision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol 15(5):1297–1303. https://doi.org/10.1245/s10434-007-9777-x
Kelly DA, Wood BC, Knoll GM, Chang SC, Crantford JC, Bharti GD, Levine EA, Thompson JT (2012) Outcome analysis of 541 women undergoing breast conservation therapy. Ann Plast Surg 68(5):435–437. https://doi.org/10.1097/SAP.0b013e31823b6ae3
Albornoz CR, Cohen WA, Razdan SN, Mehrara BJ, McCarthy CM, Disa JJ, Dayan JH, Pusic AL, Cordeiro PG, Matros E (2016) The impact of travel distance on breast reconstruction in the United States. Plast Reconstr Surg 137(1):12–18. https://doi.org/10.1097/PRS.0000000000001847
King NM, Lovric V, Parr WCH, Walsh WR, Moradi P (2017) What is the standard volume to increase a cup size for breast augmentation surgery? A novel three-dimensional computed tomographic approach. Plast Reconstr Surg 139(5):1084–1089. https://doi.org/10.1097/PRS.0000000000003247
Cochrane RA, Valasiadou P, Wilson AR, Al-Ghazal SK, Macmillan RD (2003) Cosmesis and satisfaction after breast-conserving surgery correlates with the percentage of breast volume excised. The British journal of surgery 90(12):1505–1509. https://doi.org/10.1002/bjs.4344
Moyer HR, Carlson GW, Styblo TM, Losken A (2008) Three-dimensional digital evaluation of breast symmetry after breast conservation therapy. J Am Coll Surg 207(2):227–232. https://doi.org/10.1016/j.jamcollsurg.2008.02.012
Odom EB, Parikh RP, Um G, Kantola SW, Cyr AE, Margenthaler JA, Tenenbaum MM, Myckatyn TM (2018) Nipple-sparing mastectomy incisions for cancer extirpation prospective cohort trial: perfusion, complications, and patient outcomes. Plast Reconstr Surg 142(1):13–26. https://doi.org/10.1097/PRS.0000000000004498
Overschmidt B, Qureshi AA, Parikh RP, Yan Y, Tenenbaum MM, Myckatyn TM (2018) A prospective evaluation of three-dimensional image simulation: patient-reported outcomes and mammometrics in primary breast augmentation. Plast Reconstr Surg 142(2):133e–144e. https://doi.org/10.1097/PRS.0000000000004601
Tepper OM, Unger JG, Small KH, Feldman D, Kumar N, Choi M, Karp NS (2010) Mammometrics: the standardization of aesthetic and reconstructive breast surgery. Plast Reconstr Surg 125(1):393–400. https://doi.org/10.1097/PRS.0b013e3181c4966e
Morris EA, Comstock CE, Lee CH (2013) Background parenchymal enhancement, MR breast parenchymal density, and mammographic breast density were noted in accordance with the American College of Radiology BI-RADS Atlas MR lexicon standards. In: ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. American College of Radiology, Reston
Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ (2009) Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg 124(2):345–353. https://doi.org/10.1097/PRS.0b013e3181aee807
Vrouwe SQ, Somogyi RB, Snell L, McMillan C, Vesprini D, Lipa JE (2018) Patient-reported outcomes following breast conservation therapy and barriers to referral for partial breast reconstruction. Plast Reconstr Surg 141(1):1–9. https://doi.org/10.1097/PRS.0000000000003914
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42(2):377–381. https://doi.org/10.1016/j.jbi.2008.08.010
Peled AW, Duralde E, Foster RD, Fiscalini AS, Esserman LJ, Hwang ES, Sbitany H (2014) Patient-reported outcomes and satisfaction after total skin-sparing mastectomy and immediate expander-implant reconstruction. Ann Plast Surg 72(Suppl 1):S48–52. https://doi.org/10.1097/sap.0000000000000020
Waljee JF, Hu ES, Newman LA, Alderman AK (2008) Predictors of breast asymmetry after breast-conserving operation for breast cancer. J Am Coll Surg 206(2):274–280. https://doi.org/10.1016/j.jamcollsurg.2007.07.029
Flanagan MR, Zabor EC, Romanoff A, Fuzesi S, Stempel M, Mehrara BJ, Morrow M, Pusic AL, Gemignani ML (2019) A comparison of patient-reported outcomes after breast-conserving surgery and mastectomy with implant breast reconstruction. Ann Surg Oncol 26(10):3133–3140. https://doi.org/10.1245/s10434-019-07548-9
Katariya RN, Forrest AP, Gravelle IH (1974) Breast volumes in cancer of the breast. Br J Cancer 29(3):270–273
O'Connell RL, DiMicco R, Khabra K, O'Flynn EA, deSouza N, Roche N, Barry PA, Kirby AM, Rusby JE (2016) Initial experience of the BREAST-Q breast-conserving therapy module. Breast Cancer Res Treat 160(1):79–89. https://doi.org/10.1007/s10549-016-3966-x
Waljee JF, Hu ES, Ubel PA, Smith DM, Newman LA, Alderman AK (2008) Effect of esthetic outcome after breast-conserving surgery on psychosocial functioning and quality of life. J Clin Oncol 26(20):3331–3337. https://doi.org/10.1200/JCO.2007.13.1375
Wang HT, Barone CM, Steigelman MB, Kahlenberg M, Rousseau D, Berger J, Daum A, Ortegon DP (2008) Aesthetic outcomes in breast conservation therapy. Aesth Surg J 28(2):165–170. https://doi.org/10.1016/j.asj.2007.12.001
Hennigs A, Biehl H, Rauch G, Golatta M, Tabatabai P, Domschke C, Schott S, Wallwiener M, Schutz F, Sohn C, Heil J (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. Ann Surg Oncol 23(5):1744–1751. https://doi.org/10.1245/s10434-015-4943-z
Broecker JS, Hart AM, Styblo TM, Losken A (2017) Neoadjuvant therapy combined with oncoplastic reduction for high-stage breast cancer patients. Ann Plast Surg 78(6 Suppl 5):S258–S262. https://doi.org/10.1097/SAP.0000000000001062
Grabinski VF, Myckatyn T, Lee CN, Philpott-Streiff S, Politi MC (2018) Importance of shared decision-making for vulnerable populations: examples from postmastectomy breast reconstruction. Health Equity 2:1. https://doi.org/10.1089/heq.2018.0020
Hasak JM, Myckatyn TM, Grabinski VF, Philpott SE, Parikh RP, Politi MC (2017) Stakeholders’ perspectives on postmastectomy breast reconstruction: recognizing ways to improve shared decision making. Plast Reconstr Surg Global Open. https://doi.org/10.1097/gox.0000000000001569
Politi MC, Lee CN, Philpott-Streiff SE, Foraker RE, Olsen MA, Merrill C, Tao Y, Myckatyn TM (2019) A randomized controlled trial evaluating the BREASTChoice tool for personalized decision support about breast reconstruction after mastectomy. Ann Surg. https://doi.org/10.1097/SLA.0000000000003444
Jagsi R, Li Y, Morrow M, Janz N, Alderman A, Graff J, Hamilton A, Katz S, Hawley S (2015) Patient-reported quality of life and satisfaction with cosmetic outcomes after breast conservation and mastectomy with and without reconstruction: results of a survey of breast cancer survivors. Ann Surg 261(6):1198–1206. https://doi.org/10.1097/SLA.0000000000000908
Soran A, Ibrahim A, Kanbour M, McGuire K, Balci FL, Polat AK, Thomas C, Bonaventura M, Ahrendt G, Johnson R (2015) Decision making and factors influencing long-term satisfaction with prophylactic mastectomy in women with breast cancer. Am J Clin Oncol 38(2):179–183. https://doi.org/10.1097/COC.0b013e318292f8a7
Fayanju OM, Stoll CR, Fowler S, Colditz GA, Margenthaler JA (2014) Contralateral prophylactic mastectomy after unilateral breast cancer: a systematic review and meta-analysis. Ann Surg 260(6):1000–1010. https://doi.org/10.1097/SLA.0000000000000769
Dolen UC, Schmidt AC, Um GT, Sharma K, Naughton M, Zoberi I, Margenthaler JM, Myckatyn TM (2016) Impact of neoadjuvant and adjuvant chemotherapy on immediate tissue expander breast reconstruction. Ann Surg Oncol 23(7):2357–2366. https://doi.org/10.1245/s10434-016-5162-y
Devulapalli C, Bello RJ, Moin E, Alsobrooks J, Fallas PB, Ohkuma R, Manahan MA, Sacks JM, Cooney CM, Rosson GD (2018) The effect of radiation on quality of life throughout the breast reconstruction process: a prospective, longitudinal pilot study of 200 patients with long-term follow-up. Plast Reconstr Surg 141(3):579–589. https://doi.org/10.1097/PRS.0000000000004105
Nelson JA, Lee IT, Disa JJ (2018) The functional impact of breast reconstruction: an overview and update. Plast Reconstr Surg Global Open 6(3):e1640. https://doi.org/10.1097/GOX.0000000000001640
Odom EB, Mehta N, Parikh RP, Guffey R, Myckatyn TM (2017) Paravertebral blocks reduce narcotic use without affecting perfusion in patients undergoing autologous breast reconstruction. Ann Surg Oncol. https://doi.org/10.1245/s10434-017-6007-z
Sinnott CJ, Persing SM, Pronovost M, Hodyl C, McConnell D, Ott Young A (2018) Impact of postmastectomy radiation therapy in prepectoral versus subpectoral implant-based breast reconstruction. Ann Surg Oncol. https://doi.org/10.1245/s10434-018-6602-7
Ter Louw RP, Nahabedian MY (2017) Prepectoral breast reconstruction. Plast Reconstr Surg 140:51S–59S. https://doi.org/10.1097/PRS.0000000000003942
Parikh RP, Sharma K, Guffey R, Myckatyn TM (2016) Preoperative paravertebral block improves postoperative pain control and reduces hospital length of stay in patients undergoing autologous breast reconstruction after mastectomy for breast cancer. Ann Surg Oncol. https://doi.org/10.1245/s10434-016-5471-1
The authors are grateful to Colleen Kilbourne-Glynn, Corrine Merrill, and Darlene Bird for data organization, IRB management, and administration of patient-reported outcome questionnaires throughout the study period. We are grateful to Tracey Guthrie and Annette Irving for providing compliance and administrative support and to information technology support at Washington University related to three-dimensional photography. We are grateful to Allergan Inc. for awarding the investigator-initiated grant (IIT-2017-10075) that funded this work.
This study was funded by an investigator-initiated grant from Allergan Inc. to Dr. Myckatyn (IIT-2017-10075). Dr. Myckatyn receives grant funding, consultant, and advisory board fees from Allergan, and investigator-initiated grant funding and consultant fees from RTI. Dr. Tenenbaum receives grant funding and consultant fees from Allergan, grant funding from Mentor, and advisory board and consulting fees from RTI. Dr. Appleton received consulting income from WhiteRabbit Inc. There are no other relevant disclosures for any of the authors.
Conflict of interest
Marissa M. Tenenbaum has received speaker honoraria and advisory board fees from Allergan, inc. in the last 2 years. She has received advisory board fees from RTI in the last year. Catherine Appleton declares consulting income from WhiteRabbit, Inc. Terence M. Myckatyn has received speaker honoraria and advisory board fees from Allergan, inc. in the last 2 years. Allergan is the company that funded this study via an investigator-initiated grant to Dr. Myckatyn as disclosed above. Dr. Myckatyn has also received advisory board fees from RTI in the last year and also has an active investigator-initiated research grant from RTI which is not related to this work other than the fact that, like the grant from Allergan, investigates topics under the umbrella of breast reconstruction research. Dr. Myckatyn is also a Co-Investigator on a an award from the National Institutes of Health, Agency for Health Care Research and Quality (AHRQ), R18 HS026699-01 “Implementing a breast reconstruction decision support tool in diverse practice settings.” This grant is also under the general umbrella of breast reconstruction research but not directly related to topic matter herein. The remaining authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee (the Human Research Protection Office (#201404004) at the Washington University School of Medicine) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in the study as regulated by the Human Research Protection Office (#201404004) at the Washington University School of Medicine.
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Dolen, U., Thornton, M., Tenenbaum, M.M. et al. A prospective cohort study to analyze the interaction of tumor-to-breast volume in breast conservation therapy versus mastectomy with reconstruction. Breast Cancer Res Treat 181, 611–621 (2020). https://doi.org/10.1007/s10549-020-05639-w
- Post-mastectomy reconstruction
- Patient-reported outcomes