Introduction
Breast-conserving surgery (BCS) followed by adjuvant radiotherapy, is documented to be equal to mastectomy with regard to oncological outcomes [
1‐
3], and has to a large extent replaced total mastectomy in the last few decades. Oncoplastic breast surgery (OBS) was developed with the aim of further improving the esthetic and functional outcomes of BCS [
4‐
7], as these affect health-related quality of life (HRQoL). However, only a few studies have addressed patient-reported outcomes (PROs), e.g., physical and psychosocial well-being, following OBS or among patients treated with conventional BCS [
8,
9].
Several studies have evaluated oncoplastic surgery as a concept [
4,
5,
7,
10], others have considered surgical techniques [
4,
10], postoperative complications [
6,
10,
11], as well as oncological [
6,
11,
12] and esthetical outcomes [
6,
11,
13‐
15]. With the development of the Breast-Q™ [
16,
17] and recently the Breast-Q™ BCT module, a validated instrument for patient-reported outcome measures (PROMs) is now available.
OBS can be defined as level I and level II surgical techniques [
7,
18] and OBS can be considered as an extension of conventional BCS [
10]. By applying OBS in BCS, a larger number of patients may achieve good esthetic and functional outcomes, and some may also escape mastectomy [
6,
7,
11,
19,
20].
The aim of this study was to investigate whether OBS improves HRQoL in patients undergoing BCS. For this purpose, we used the Breast-Q™ BCT module.
Discussion
In this study, we evaluated the outcome of OBS compared with BCS using the Breast-Q™ BCT postoperative module. We found that patients treated with OBS had a better “Psychosocial Well-being “. However, no significant differences were found for the domains “Physical Well-being”, “Satisfaction with Breast” or “Sexual Well-being”.
Evaluation of surgical treatment of breast cancer by oncological outcomes remains essential. However, the quality of the health care services provided also needs attention. There is now an increasing demand to evaluate how patients perceive the results of treatment, i.e., PRO [
8,
9,
19]. In this study we took advantage of Breast-Q™ which can be used as a standardized and validated instrument for evaluation of HRQoL in patients operated for breast cancer [
16,
31‐
33].
Although the esthetic and functional outcome of OBS compared with BCT has been investigated before [
15], there have been few studies comparing HRQoL between OBS and BCS so far. The Breast-Q™ BCT pre- and postoperative module was introduced in 2015. One year later, O´Connell et al. [
8] published their initial experience with the full BCT postoperative module including 200 patients, thus establishing a benchmark for future research. However, few studies have addressed the HRQoL outcome of BCS [
8,
9,
16] and OBS [
34] or both. Compared with previous studies, patients included in the OBS cohort in this study represent the full spectrum of OBS, i.e., level I and II surgery, and the sample is therefore not restricted to one surgical procedure such as the therapeutic mammoplasty technique [
34].
In the domain “Psychosocial Well-being” we found a median score of 82, similar to the results of O´Connell [
8] and Dahlbäck [
35], using Breast-Q™ for evaluation of the outcome of BCT, while Langendiik [
36] found a mean score at 70.1 and Vesprini [
9] found a mean score at 73.5. In our study we found a statistically significant better outcome for the OBS cohort, including level I and II surgery, compared with the BCS cohort. The difference was strengthened by including only level II surgery from the OBS cohort.
In their analyses of the domain “Physical Well-being” after BCT with Breast-Q™, Langendjik [
36] and Vesprini [
9] found mean scores of 71.2 and 74, respectively. A slightly higher score of 75 was reported by O`Connell [
8]. The median score of 78 in this study reflects a low grade of physical discomfort and there was no statistically significant difference between OBS and BCT. One could have expected a lower score for the OBS cohort, particularly in cases of level II surgery as this surgery is more extensive and often involves the contralateral breast. On the contrary, there was a slight difference in the figures, indicating better outcomes for OBS compared with BCS.
In the analysis of the domain “Satisfaction with Breast” Vesprini [
9] and Langendjik [
36] found mean scores of 59.3 and 65.7, respectively, while Dahlbäck [
35] and O´Connell [
8] found median scores of 66 and 68, respectively. Hence, our median score of 74 in the present study means our scores are higher than those reported previously and they indicate a higher degree of satisfaction with the breast. High scores generally imply that possible differences are difficult to detect and, consequently, we found no difference between OBS and BCS. However, when only level II surgery was considered, a tendency toward a better outcome in the OBS group was noted.
The domain “Sexual Well-being” had a markedly lower median score of 58 and, furthermore, the response rate was low at 69.6%. This pattern has also been seen in previous studies investigating BCT [
8,
9,
36], and it seems to be a general issue for this domain. Therefore, results must be interpreted with caution. We found no difference between OBS and BCS. However, when only level II surgery was considered, a slight tendency toward a better outcome in the OBS group was noted.
In summary, the results show that patients treated with OBS reported statistically better psychosocial health than those treated with BCS. Patients treated with OBS also scored slightly higher for the domains “Satisfaction with breasts” and “Sexual Well-being” particularly when the analyses only included level II OBS, although the difference was not statistically significant. Notably, the results in the domain “Physical Well-being” showed no significant differences despite the fact that patients treated with OBS had more extensive and often bilateral surgery.
A methodological issue to be considered is the definition of OBS. In studies published in the last few decades, the definition of OBS has varied, making it difficult to compare the outcome results from different studies. In the present study, we have based our definition on that proposed by Clough et al. [
7], which is widely accepted. In the publication by Chatterjee et al. [
18], a consensus definition and classifications system, developed by the American Society of Breast Surgeons, was presented which was strongly influenced by Clough’s definition [
7]
. By using a widely accepted definition of OBS we hope that the results from the present study can be used for comparison with future studies.
Another methodological issue to be considered is the PROM instrument chosen. The Breast-Q™ BCT module is now widely accepted as a valuable PROM instrument for breast-conserving surgery [
31,
3237], which is why we have chosen the Breast-Q™ BCT postoperative module.
Furthermore, the validity of the data used must be considered. Data in the research database were only used for identification of patients treated with OBS. To avoid misclassification of patient, tumor and treatment characteristics, all data for both the OBS and the BCS cohorts were obtained from the national DBCG registry [
21]. In a recent study by Cronin-Fenton et al., [
38] the authors conclude that DBCG data are valid for epidemiological studies of breast cancer treatment; thus, we believe that the validity of the data is good.
To avoid confounding by indication, the patients in the OBS and BCS cohorts were recruited from different geographical regions. The unselected demographic BCS cohort thus also possibly included some more advanced cases that might have been selected for OBS. In the early study period, such cases were not identified, but from 1 July 2010, 24 cases could be identified in the DBCG registry. Sensitivity analyses excluding these patients did not alter the results. The OBS cohort may include patients with relatively more advanced disease, i.e., the OBS cohort could include patients with tumor and treatment characteristics known to predict less satisfying outcomes of HRQoL. By adjusting for these variables in the statistical analyses, we have reduced this potential selection bias.
Response rates in other surveys are reported to be between 31% [
9] and 76% [
35]. With a total response rate in our study of 48.3% for evaluable replies (OBS cohort 48.4%, BCS cohort 48.0%) we find our response rate acceptable. The analysis comparing patients in the responder and the non-responder cohorts showed only minor differences, that is, the responder cohort is considered representative of the survey cohort, showing no selection bias.
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