Continuing Education Activity

Breast cancer is a leading cause of cancer-related deaths among females in the world. The rapid growth of breast conservation therapy has significantly changed the management of early breast cancer, with outcomes shown to be equivalent to mastectomy when combined with radiation. This activity reviews the role of breast-conserving therapy in breast cancer treatment. It highlights the role of the interprofessional team in improving care for patients who undergo breast conservation therapy.

Objectives:

• Identify Implthe indications for breast conservation therapy in the management of early-stage breast cancer.
• Determine the preoperative workup, operative steps, and post-operative follow-up for partial mastectomy with axillary lymph node mapping.
• Identify the most common adverse events following breast conservation therapy and associated risk factors.
• Implement interprofessional team strategies for improving care coordination and communication to advance breast-conserving therapy and improve outcomes.

Introduction

Breast cancer ranks among the leading causes of female cancer-related deaths in the world.[1] Surgical management remains the standard of care for noninvasive and localized invasive breast cancer, which may be combined with systemic endocrine therapy, chemotherapy, or radiation. With the publication of the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-06 trial, which showed equivalent disease-free survival, distant disease-free survival, and overall survival amongst women undergoing partial mastectomy with irradiation compared to radical mastectomy, breast conservation therapy (BCT) became standard of care for patients with tumors under 4 cm.[2]

These results received confirmation in multiple studies, including a 20-year follow-up of the NSABP B-06 trial, where partial mastectomy followed by breast radiation continues to be appropriate in the management of smaller invasive breast cancer tumors.[3][4] Additionally, BCT, when combined with radiation, became the standard of care for localized intraductal breast cancers (eg, ductal carcinoma in situ [DCIS]). This development occurred after the NSABP B-17 trial, where the addition of radiation significantly decreased the recurrence rate of noninvasive and invasive breast cancers.[5]

Identified advantages of BCT include reduced operative time, diminished psychological burden when compared with mastectomy, improved cosmetic outcomes, and limited side effects.[6][7] However, other studies have demonstrated no significant difference in depressive symptoms at one year post-operatively between women who underwent a total mastectomy, BCT, and breast reconstruction.[8]

Proper staging is critical for determining the appropriate clinical treatment course and surgical planning. In 2018, the American Joint Committee on Cancer (AJCC) released the eighth edition of the Cancer Staging Manual for Breast Cancer. This staging includes the T (tumor), N (node), and M (metastases) staging, but incorporated biologic markers into the traditional staging system. Factors including estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), tumor grade, and multigene assays were included to aid in determining prognosis and therapy as determined by a Clinical and Pathologic Prognostic Stage Group.[9]

Indications

BCT should be a consideration when the surgeon feels that a tumor can undergo excision with clear margins with an acceptable cosmetic result. Adequate margins if there is "no ink on tumor" seen for invasive carcinomas, and 2 mm margins are the recommendation for DCIS.[10][11] Lumpectomy is typically recommended for DCIS/Tis and T1-2 tumors if there are no other contraindications to adjuvant radiation. However, adjuvant radiation results in only a small improvement in locoregional recurrence but not improved overall survival, distant disease-free survival, or breast preservation in patients 70 years old or older with clinical stage I (T1N0M0), ER-positive carcinomas receiving adjuvant tamoxifen.[12] Therefore, the omission of adjuvant radiation in these patients is reasonable.

Contemporary studies have addressed the role of BCT following neoadjuvant chemotherapy for lesions greater than 5 cm. However, tumor size relative to breast size may be more important than exact measurements alone. Evaluation of breast size and discussion with the patient regarding postoperative expectations of her breast size is therefore critical to deciding the best treatment course. Neoadjuvant chemotherapy has demonstrated comparable rates of disease-free survival and overall survival when compared with adjuvant therapy. It may convert patients with large tumors to candidates for breast conservation therapy.[13] In patients with locally advanced tumors who have an excellent response to neoadjuvant chemotherapy, BCT may offer a safe surgical option rather than a total mastectomy.[14]

Male patients have historically received the recommendation to undergo a mastectomy. While this is still the preferred surgical procedure, BCT can be an option in patients with multiple comorbidities or those who desire to preserve their nipple-areolar complex. Although male patients undergoing BCT were less likely to receive standard-of-care therapy, breast cancer-specific survival was not affected by surgery type.[15] However, recommendations typically include adjuvant radiation.

Contraindications

Relative Contraindications

• Prior radiation therapy to the chest wall or breast
• Active connective tissue disease involving the skin (ie, scleroderma)
• Extensive positive pathological margins
• Tumors greater than 5 cm
• Large tumor size relative to breast size
• Known or suspected Li-Fraumeni syndrome (p53 mutation)
• Women with a known or suspected genetic predisposition to breast cancer (ie, BRCA1, BRCA2)

Absolute Contraindications

• First-trimester pregnancy (Radiation therapy is contraindicated during pregnancy; however, pending other treatments needed, BCT is reasonable for some 2nd and many 3rd trimester patients who can receive radiation after delivery.)
• Multicentric disease 
• Diffuse suspicious or malignant appearing microcalcifications
• Extensive DCIS
• Inflammatory breast cancer
• Tumors for which clear margins are unobtainable with lumpectomy with favorable cosmetic results
• Homozygous for ATM mutation

Preparation

Following identification of a concerning lesion on imaging (calcifications or masses), a core needle biopsy of the lesion is preferable over excisional biopsies for optimal surgical treatment. When performed, a small clip gets placed in the biopsy area to confirm the biopsied region and mark the location of concern for future surgical treatments. This clip is especially helpful for lumpectomies for nonpalpable cancers or DCIS that require radiologic identification. Clip placement is crucial in patients undergoing neoadjuvant chemotherapy, as localization of the tumor can become extremely difficult in patients who achieve significant clinical responses. 

The most commonly used approach to this is wire-guided localization. A radiologist or operating surgeon typically performs this procedure on the same day as surgery. Under stereotactic or ultrasound guidance, a wire is inserted through the skin and terminates at the lesion or area of concern.[16] Soft compression mammographic images are obtainable after wire localization confirms the relation of the wire to the suspected lesion for surgical planning. This wire then serves as a guide for surgical excision and gets removed with the surgical specimen.

There are disadvantages to wire-guided localization, including the presence of a foreign body at the pathological assessment, wire transection, migration, patient discomfort, injury associated with wire barbs, and pneumothorax, which have led to the development of alternative localization approaches.[17] Additionally, if the operating surgeon is not performing the localization in the operating room, surgical scheduling may be more difficult as coordination with the performing radiologist is needed. Wireless localization of nonpalpable lesions has, therefore, become increasingly popular. The most common wireless technologies used are markers that use radiofrequency, radar or infrared, or paramagnetic iron oxide. Radio-guided occult lesion localization involves a nonspecific radio-isotope, commonly technetium-99, injected into the tumor and identified intraoperatively with a hand-held gamma probe.[17] This technique has been deemed increasingly feasible. Other less utilized approaches include intraoperative ultrasound-guided resection, cryoprobe-assisted localization, carbon marking, methylene blue dye marking, and near-infrared fluorescence optical imaging.[17]

Technique or Treatment

Following a localization procedure, the surgeon performs the lumpectomy with the patient in the supine position with the ipsilateral arm at 90 degrees. The incision location can be planned either near or distant from the location of the lesion. Incisions may be placed within the Langer lines over the mass when possible and made large enough to avoid excess manipulation when delivering the specimen from the field. A short, curvilinear incision may suffice for small tumors versus a radial incision for large tumors, which may result in less distortion of the nipple-areolar complex. With more emphasis on cosmesis, the use of more conspicuous regions of the breast has become popular, which include periareolar, inframammary, or axillary incisions.

The incision is opened, and dissection is carried down into the breast tissue. Skin flaps are raised in all directions over the mass or area of concern. Sufficient subcutaneous fat should be left in place to provide adequate blood supply to the flaps as they are elevated. Occasionally, the skin may require resection to obtain sufficient margins for superficial lesions or prevent ischemia. Dissection is carried down just above the identified tumor and then completed circumferentially. The tumor is excised with enough surrounding tissue to ensure that inked specimen margins are free of tumor. If needle localization is performed, identification of the thickened portion of the wire allows a better estimation of the lesion location and margins needed. Pectoral fascia and muscle are only removed if required to obtain tumor-free margins. The specimen is oriented before removal from the surgical field with suture or ink. When performed, the specimen is inked on six sides, either by the operating surgeon or a pathologist.

Intraoperative specimen imaging is then typically performed to confirm the location of the biopsy clip, possible marker (wire or wireless), and to ensure adequate margins if the lesion is visible. Mammogram of the specimen is common, although other modalities are also options. The cavity margins are inspected for remaining suspicious tissue. Re-excision of a suspected close margin may be performed by removing another 0.5 cm  to 1 cm of tissue, appropriately oriented for the pathologist. Some surgeons also take "shave margins," where at least an additional 1 mm of tissue gets taken from the cavity. This practice may lower both margin positivity and re-excision rates.[18][19] The cavity is then marked for guiding future radiation. Titanium clips are placed at the superior, inferior, medial, lateral, and posterior margins. Three-dimensional, absorbable markers are also an option, which may provide benefits for radiation guidance and result in overall lower tumor bed volume.[20][21]

Oncoplastic techniques may be utilized to achieve adequate tissue resection and an acceptable cosmetic outcome without the need for breast reconstruction. Oncoplastic surgery is a form of breast conservation that uses volume replacement or tissue displacement techniques to optimize aesthetic results following partial mastectomy.[22] With increasing popularity, several studies have examined the safety of oncoplastic surgery with evidence suggesting a decreased rate of re-excision and improved rate of negative margins,[23][24] psychosocial and aesthetic benefits,[25] and cost-effectiveness.[22] However, patients should be carefully selected and counseled, as tissue rearrangement procedures should be avoided in patients who actively smoke or have significant comorbidities that may impede wound healing or increase a patient's risk for flap or tissue necrosis.[26] Tissue rearrangement can be problematic in the extremely fatty breast. Patients with small breast sizes may also be at increased risk for deformity or decreased cosmetic outcomes. Overall, most studies have shown similar rates of surgical complications amongst patients who undergo oncoplastic surgery vs. standard breast conservation surgery.[27] One single-institution study found that oncoplastic surgery resulted in fewer postoperative seromas compared to standard breast-conserving therapy but noted an increased rate of wound-related complications.[28]

These procedures are categorized as Level 1 and Level 2 procedure types. Surgeons consider Level 1 procedures when excising less than 20% of breast tissue in small-to-moderate-sized breasts. These procedures involve aesthetically placed incisions either at the inframammary crease, periareolar margin, or axilla.[22] Following excision of the specimen, the surgeon creates dermoglandular planes using superficial and deep dissection to fill in the created tissue void; this is performed after marking the cavity for radiation. Examples of Level 1 procedures include local tissue rearrangement, crescent mastopexy, and doughnut mastopexy.

Level 2 procedures are those that require the removal of 20% to 50% of breast tissue in moderate to large-sized breasts with moderate to severe ptosis.[22] Level 2 techniques often involve the development of a pedicle with a circumvertical or wise skin incision pattern. Examples of level 2 procedures include circumvertical mastopexy design and reduction mammoplasty. Breast asymmetry has not shown itself to be a significant issue as a contralateral symmetry procedure during or even after the index operation can be performed. Any procedure requiring the removal of more than 50% of breast tissue merits consideration for volume replacement reconstruction.

Regional lymph node staging is performed in conjunction with breast-conserving therapy. The sentinel lymph node is most likely to contain metastatic disease and is identified and removed via an axillary incision. Identification of the sentinel axillary lymph node uses either a radiolabeled colloid, injection of isosulfane or methylene blue dye, or both. The use of dual tracer has shown to have higher rates of node identification and lower false-negative rates.[29] Further, the need for axillary intervention is determined based on the number of positive nodes as outlined by the ACOSOG Z0011 trial.[30] For patients with T1-T2 tumors with 1 to 2 positive sentinel lymph nodes (without gross extranodal extension) who plan to undergo whole breast radiation, no further axillary surgery is necessary.[30][31]

Complications

Complications of breast cancer conservation therapy include:

• Seroma
• Hematoma
• Fat necrosis
• Infection with the development of cellulitis or abscess
• Altered sensation to the breast or nipple
• Close or positive margins
• Poor cosmetic outcome
• Lymphedema following sentinel lymph node biopsy
• Wound dehiscence, especially in oncoplastic technique; most commonly seen at the inverted T-junction in a wise incision pattern [22]

Clinical Significance

Patients with invasive breast cancer who undergo BCT should receive postoperative whole breast radiation as recommended by the National Comprehensive Cancer Network (NCCN) guidelines. The purpose of radiotherapy is to eradicate any microscopic foci of remaining tumor cells in the conserved breast tissue to prevent local recurrence and distant metastasis. The addition of radiotherapy halved local recurrence rates, and there was an estimated 5% absolute reduction in breast cancer death at 15 years.[7] However, interest in accelerated partial breast radiation, intraoperative radiation, and brachytherapy (with the placement of catheters in the resection cavity) has been increasing.

Additional adjunctive endocrine therapy has its basis on hormone receptor status, which is estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER-2)/Neu status and is discussed elsewhere. For those patients with triple-negative expression, BCT merits consideration, but chemotherapy is a recommendation.[7][31][7] For patients with a diagnosis of ductal carcinoma in situ, considered to be a precursor for invasive carcinoma, similar considerations are necessary to determine if BCT is appropriate.

Following curative treatment of nonmetastasized breast cancer with breast-conserving therapy, imaging surveillance is of utmost importance to monitor for locoregional recurrence. Bilateral mammography 6 to 12 months after completing radiation therapy, followed by an annual screening mammogram and biannual breast exam, is the recommended procedure.[32] Routine use of annual contrast-enhanced MRI is generally not recommended except in high-risk patients such as those with familial/genetic risk of recurrence, dense breast tissue, and diagnosis under the age of 50.[32] This approach should not replace annual mammography but rather serve as an adjunct, often alternating with mammography for biannual imaging.

Enhancing Healthcare Team Outcomes

Interprofessional oncology teams incorporate a wide range of clinical specialists, including those in surgery, medical oncology, radiation oncology, genetics, pathology, specialist cancer nurses, and oncology pharmacists, to discuss the needs of patients with a confirmed cancer diagnosis. Globally, many healthcare systems address these needs at weekly interprofessional meetings.[33] Nursing is usually responsible for any medication administration accompanying breast-conserving surgery, and the oncology pharmacist will weigh in for checking dosing and agent selection options, working in conjunction with the oncologist and other clinicians.

Retrospective studies have shown improved breast cancer survival rates when treated by an interprofessional team.[34] Moving forward, it is essential not only to continue utilizing interprofessional team meetings but also to optimize team dynamics and productivity to enhance patient-centered care and improve outcomes.

Nursing, Allied Health, and Interprofessional Team Interventions

Nursing interventions for the patient undergoing BCT encompass the preoperative period, immediate postoperative, and long-term monitoring and surveillance of the patient. The most important preoperative action is to obtain arm measurements of the affected side; this provides the healthcare team with a baseline for lymphedema monitoring. Patients often fear lymphedema. Arm measurement is critical to providers but also reassures the patient that they receive close observation to ensure quick action if postoperative swelling does occur. This time also provides an opportunity to teach the patient a gentle range of motion exercises to prevent swelling.  

Secondly, it is crucial to provide thorough education surrounding the operation. Although surgeons do review the procedure and postoperative restrictions, many patients may be overwhelmed at that time. This stress may inhibit the patient, and their family, from thoroughly comprehending the information. A personal, one-on-one conversation can ensure the patient understands the operation. Reviewing the wire or wireless localization is necessary as many patients have a biopsy marker and may not understand why the area needs to be localized. The clinician should also review the purpose of sentinel lymph node biopsy, as many patients misconstrue this, assuming cancer has spread to the lymph nodes.

In the immediate postoperative period, the nurse can address pain control. Education on the dosage of prescription and over-the-counter medication ensures patient safety. If a patient underwent oncoplastic surgery, she must understand that she must refrain from the use of ice on her breast for pain management, as this may compromise wound healing.

During the balance of the patient’s postoperative period, education remains essential. Patients are anxious and eager about the "next step." This patient counsel provides time to review the cadence of treatment and the role of other specialties. The clinician should also take arm measurements beginning at 3 months postoperatively through 5 years to monitor for signs of lymphedema.

Nursing, Allied Health, and Interprofessional Team Monitoring

Clinicians must monitor patients undergoing BCT postoperatively for possible adverse reactions, both immediate and long-term. Immediate monitoring focuses primarily on incision assessment. Clinicians must watch for possible signs of infection, including warmth, erythema, fever, and purulent drainage. They should monitor for swelling as it may indicate a hematoma. Patients should receive instructions to call the office if they develop any of these symptoms. Long-term monitoring includes assessment for signs and symptoms of lymphedema through visual observation and performing arm circumference measurements.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

References

1.

Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. [PubMed: 30207593]

2.

Fisher B, Bauer M, Margolese R, Poisson R, Pilch Y, Redmond C, Fisher E, Wolmark N, Deutsch M, Montague E. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med. 1985 Mar 14;312(11):665-73. [PubMed: 3883167]

3.

Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N. 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. 2002 Oct 17;347(16):1233-41. [PubMed: 12393820]

4.

Early Breast Cancer Trialists' Collaborative Group. Effects of radiotherapy and surgery in early breast cancer. An overview of the randomized trials. N Engl J Med. 1995 Nov 30;333(22):1444-55. [PubMed: 7477144]

5.

Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, Fisher ER, Wickerham DL, Deutsch M, Margolese R, Dimitrov N, Kavanah M. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol. 1998 Feb;16(2):441-52. [PubMed: 9469327]

6.

Bleicher RJ, Ruth K, Sigurdson ER, Ross E, Wong YN, Patel SA, Boraas M, Topham NS, Egleston BL. Preoperative delays in the US Medicare population with breast cancer. J Clin Oncol. 2012 Dec 20;30(36):4485-92. [PMC free article: PMC3518727] [PubMed: 23169513]

7.

Nijenhuis MV, Rutgers EJ. Who should not undergo breast conservation? Breast. 2013 Aug;22 Suppl 2:S110-4. [PubMed: 24074770]

8.

Zhang C, Hu G, Biskup E, Qiu X, Zhang H, Zhang H. Depression Induced by Total Mastectomy, Breast Conserving Surgery and Breast Reconstruction: A Systematic Review and Meta-analysis. World J Surg. 2018 Jul;42(7):2076-2085. [PubMed: 29426972]

9.

Giuliano AE, Edge SB, Hortobagyi GN. Eighth Edition of the AJCC Cancer Staging Manual: Breast Cancer. Ann Surg Oncol. 2018 Jul;25(7):1783-1785. [PubMed: 29671136]

10.

Schnitt SJ, Moran MS, Houssami N, Morrow M. The Society of Surgical Oncology-American Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer: Perspectives for Pathologists. Arch Pathol Lab Med. 2015 May;139(5):575-7. [PubMed: 25153620]

11.

Morrow M, Van Zee KJ, Solin LJ, Houssami N, Chavez-MacGregor M, Harris JR, Horton J, Hwang S, Johnson PL, Marinovich ML, Schnitt SJ, Wapnir I, Moran MS. Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology Consensus Guideline on Margins for Breast-Conserving Surgery with Whole-Breast Irradiation in Ductal Carcinoma In Situ. Ann Surg Oncol. 2016 Nov;23(12):3801-3810. [PMC free article: PMC5047939] [PubMed: 27527714]

12.

Hughes KS, Schnaper LA, Bellon JR, Cirrincione CT, Berry DA, McCormick B, Muss HB, Smith BL, Hudis CA, Winer EP, Wood WC. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol. 2013 Jul 01;31(19):2382-7. [PMC free article: PMC3691356] [PubMed: 23690420]

13.

Sweeting RS, Klauber-Demore N, Meyers MO, Deal AM, Burrows EM, Drobish AA, Anders CK, Carey LA. Young women with locally advanced breast cancer who achieve breast conservation after neoadjuvant chemotherapy have a low local recurrence rate. Am Surg. 2011 Jul;77(7):850-5. [PMC free article: PMC4167782] [PubMed: 21944346]

14.

Sun Y, Liao M, He L, Zhu C. Comparison of breast-conserving surgery with mastectomy in locally advanced breast cancer after good response to neoadjuvant chemotherapy: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2017 Oct;96(43):e8367. [PMC free article: PMC5671859] [PubMed: 29069026]

15.

Cloyd JM, Hernandez-Boussard T, Wapnir IL. Outcomes of partial mastectomy in male breast cancer patients: analysis of SEER, 1983-2009. Ann Surg Oncol. 2013 May;20(5):1545-50. [PubMed: 23460016]

16.

Demiral G, Senol M, Bayraktar B, Ozturk H, Celik Y, Boluk S. Diagnostic Value of Hook Wire Localization Technique for Non-Palpable Breast Lesions. J Clin Med Res. 2016 May;8(5):389-95. [PMC free article: PMC4817579] [PubMed: 27081425]

17.

Chan BK, Wiseberg-Firtell JA, Jois RH, Jensen K, Audisio RA. Localization techniques for guided surgical excision of non-palpable breast lesions. Cochrane Database Syst Rev. 2015 Dec 31;2015(12):CD009206. [PMC free article: PMC8881987] [PubMed: 26718728]

18.

Chagpar AB, Killelea BK, Tsangaris TN, Butler M, Stavris K, Li F, Yao X, Bossuyt V, Harigopal M, Lannin DR, Pusztai L, Horowitz NR. A Randomized, Controlled Trial of Cavity Shave Margins in Breast Cancer. N Engl J Med. 2015 Aug 06;373(6):503-10. [PMC free article: PMC5584380] [PubMed: 26028131]

19.

Dupont E, Tsangaris T, Garcia-Cantu C, Howard-McNatt M, Chiba A, Berger AC, Levine EA, Gass JS, Gallagher K, Lum SS, Martinez RD, Willis AI, Pandya SV, Brown EA, Fenton A, Mendiola A, Murray M, Solomon NL, Senthil M, Ollila DW, Edmonson D, Lazar M, Namm JP, Li F, Butler M, McGowan NE, Herrera ME, Avitan YP, Yoder B, Walters LL, McPartland T, Chagpar AB. Resection of Cavity Shave Margins in Stage 0-III Breast Cancer Patients Undergoing Breast Conserving Surgery: A Prospective Multicenter Randomized Controlled Trial. Ann Surg. 2021 May 01;273(5):876-881. [PubMed: 31290763]

20.

Cross MJ, Lebovic GS, Ross J, Jones S, Smith A, Harms S. Impact of a Novel Bioabsorbable Implant on Radiation Treatment Planning for Breast Cancer. World J Surg. 2017 Feb;41(2):464-471. [PubMed: 27709273]

21.

Foster B, Sindhu K, Hepel J, Wazer D, Graves T, Taneja C, Wiggins D, Leonard K. Three-Dimensional Bioabsorbable Tissue Marker Placement is Associated with Decreased Tumor Bed Volume Among Patients Receiving Radiation Therapy for Breast Cancer. Pract Radiat Oncol. 2019 Mar;9(2):e134-e141. [PubMed: 30268431]

22.

Patel K, Bloom J, Nardello S, Cohen S, Reiland J, Chatterjee A. An Oncoplastic Surgery Primer: Common Indications, Techniques, and Complications in Level 1 and 2 Volume Displacement Oncoplastic Surgery. Ann Surg Oncol. 2019 Oct;26(10):3063-3070. [PubMed: 31342388]

23.

De La Cruz L, Blankenship SA, Chatterjee A, Geha R, Nocera N, Czerniecki BJ, Tchou J, Fisher CS. Outcomes After Oncoplastic Breast-Conserving Surgery in Breast Cancer Patients: A Systematic Literature Review. Ann Surg Oncol. 2016 Oct;23(10):3247-58. [PubMed: 27357177]

24.

Losken A, Dugal CS, Styblo TM, Carlson GW. A meta-analysis comparing breast conservation therapy alone to the oncoplastic technique. Ann Plast Surg. 2014 Feb;72(2):145-9. [PubMed: 23503430]

25.

Kelsall JE, McCulley SJ, Brock L, Akerlund MTE, Macmillan RD. Comparing oncoplastic breast conserving surgery with mastectomy and immediate breast reconstruction: Case-matched patient reported outcomes. J Plast Reconstr Aesthet Surg. 2017 Oct;70(10):1377-1385. [PubMed: 28712883]

26.

Voineskos SH, Frank SG, Cordeiro PG. Breast reconstruction following conservative mastectomies: predictors of complications and outcomes. Gland Surg. 2015 Dec;4(6):484-96. [PMC free article: PMC4647007] [PubMed: 26645003]

27.

Campbell EJ, Romics L. Oncological safety and cosmetic outcomes in oncoplastic breast conservation surgery, a review of the best level of evidence literature. Breast Cancer (Dove Med Press). 2017;9:521-530. [PMC free article: PMC5552002] [PubMed: 28831273]

28.

Carter SA, Lyons GR, Kuerer HM, Bassett RL, Oates S, Thompson A, Caudle AS, Mittendorf EA, Bedrosian I, Lucci A, DeSnyder SM, Babiera G, Yi M, Baumann DP, Clemens MW, Garvey PB, Hunt KK, Hwang RF. Operative and Oncologic Outcomes in 9861 Patients with Operable Breast Cancer: Single-Institution Analysis of Breast Conservation with Oncoplastic Reconstruction. Ann Surg Oncol. 2016 Oct;23(10):3190-8. [PubMed: 27406093]

29.

Chagpar AB, Martin RC, Scoggins CR, Carlson DJ, Laidley AL, El-Eid SE, McGlothin TQ, Noyes RD, Ley PB, Tuttle TM, McMasters KM. Factors predicting failure to identify a sentinel lymph node in breast cancer. Surgery. 2005 Jul;138(1):56-63. [PubMed: 16003317]

30.

Giuliano AE, Hunt KK, Ballman KV, Beitsch PD, Whitworth PW, Blumencranz PW, Leitch AM, Saha S, McCall LM, Morrow M. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011 Feb 09;305(6):569-75. [PMC free article: PMC5389857] [PubMed: 21304082]

31.

Telli ML, Gradishar WJ, Ward JH. NCCN Guidelines Updates: Breast Cancer. J Natl Compr Canc Netw. 2019 May 01;17(5.5):552-555. [PubMed: 31117035]

32.

Swinnen J, Keupers M, Soens J, Lavens M, Postema S, Van Ongeval C. Breast imaging surveillance after curative treatment for primary non-metastasised breast cancer in non-high-risk women: a systematic review. Insights Imaging. 2018 Dec;9(6):961-970. [PMC free article: PMC6269345] [PubMed: 30411278]

33.

Soukup T, Lamb BW, Weigl M, Green JSA, Sevdalis N. An Integrated Literature Review of Time-on-Task Effects With a Pragmatic Framework for Understanding and Improving Decision-Making in Multidisciplinary Oncology Team Meetings. Front Psychol. 2019;10:1245. [PMC free article: PMC6634259] [PubMed: 31354555]

34.

Kesson EM, Allardice GM, George WD, Burns HJ, Morrison DS. Effects of multidisciplinary team working on breast cancer survival: retrospective, comparative, interventional cohort study of 13 722 women. BMJ. 2012 Apr 26;344:e2718. [PMC free article: PMC3339875] [PubMed: 22539013]

Disclosure: Rebecca Jordan declares no relevant financial relationships with ineligible companies.

Disclosure: Jacqueline Oxenberg declares no relevant financial relationships with ineligible companies.