Oncoplastic breast-conserving surgery: advancing oncological outcomes and aesthetic standards in breast cancer treatment

In recent years, the management of breast cancer has undergone significant evolution, driven by advancements in surgical techniques and an improved understanding of disease biology, leading to risk-adapted optimization of breast cancer treatment. Central to this evolution is breast-conserving surgery (BCS) combined with radiation therapy (RT), which has challenged the traditional equivalence of mastectomy.

BCS and superior overall survival (OS)

Randomized controlled trials (RCTs) from the 1970s demonstrated comparable long-term survival between BCS with radiation and mastectomy (1). However, in the modern era of advanced systemic and radiation therapies, recent evidence suggests that BCS followed by radiation may offer better OS compared to mastectomy for early-stage breast cancer (2). A recent meta-analysis involving 1,500,000 patients confirmed better OS with BCS compared to mastectomy [risk ratio (RR) 0.64, 95% confidence interval (CI): 0.55–0.74]. This benefit was consistent across diverse cohorts and multi-institutional databases (RR 0.57, 95% CI: 0.49–0.67) and was most pronounced in patients with less than 10 years of follow-up (RR 0.54, 95% CI: 0.46–0.64) (3). However, extended follow-up studies have revealed an increased local and regional recurrence with BCS plus RT compared to mastectomy (2).

To explain these clinical observations, we proposed a hypothesis based on the homing phenomenon of cancer cells (2). We postulated that reactivated circulating and disseminated tumor cells (CTCs and DTCs) possess innate breast-homing capabilities, returning to the breast of origin, where the tumor microenvironment (TME) promotes their proliferation and survival, leading to in-breast tumor recurrence (IBTR) or regional recurrence rather than distant metastases. This hypothesis suggests that BCS may be associated with a lower incidence of fatal distant metastasis and improved OS compared to mastectomy, although the incidence of IBTR may be higher (2). According to our hypothesis, CTCs and DTCs are more likely to return to the breast of origin rather than establish in distant organs. This would account for why BCS is associated with a higher rate of local recurrence while simultaneously reducing the risk of distant metastases and improving OS. In the case of mastectomy, the CTCs and DTCs are not preferentially drawn to the TME, and thus are more likely to lead to distant metastases, thus impacting OS.

Additionally, RT may exert systemic anti-tumor effects by stimulating an immune response against tumor-associated antigens. Psychological benefits associated with BCS could also contribute to the improved OS observed in these patients (2).

Furthermore, the OS benefit of BCS over mastectomy extends to ipsilateral breast cancer recurrence in patients treated with BCS and RT. A recent meta-analysis showed that repeated BCS (with or without repeat RT) was correlated with improved OS (RR 1.040, 95% CI: 1.003–1.079; P=0.032) (4).

Oncoplastic surgery: expanding the reach of BCS

Since its inception in 1990, oncoplastic breast-conserving surgery (OBCS) has been transformative in reducing the need for mastectomy, even in complex cases requiring extensive resections (5). OBCS combines oncological precision with plastic surgery techniques to optimize outcomes. Key approaches include volume displacement, which reshapes remaining breast tissue using techniques like mastopexy or reduction mammoplasty, and volume replacement, which uses autologous tissue, such as local fibroglandular or thoracic perforator flaps, to fill defects. Techniques like mobilizing local flaps or the round block method, with a circumareolar incision for centrally located tumors, minimize scarring and preserve breast contour. These methods enable larger resections, improve symmetry, and ensure oncological safety, especially in cases with unfavorable tumor-to-breast size ratios (6). Preserving breast contour not only improves physical appearance but also addresses the psychological impact of breast cancer surgery, enhancing patient satisfaction and overall quality of life. Patients who undergo BCS report higher levels of body image satisfaction and lower rates of depression compared to those who undergo mastectomy (2).

A recent multicenter prospective cohort study demonstrated that when offered OBCS as an alternative to mastectomy, most women opted for OBCS. Breast conservation was successfully achieved in over 90% of cases, with lower major complication rates compared to immediate breast reconstruction. Additionally, OBCS may improve patient satisfaction with surgical outcomes (7).

OBCS techniques also include lipofilling as a secondary adjunct procedure (8). Our meta-analysis of over 18,000 patients confirmed the oncological safety of OBCS, showing no compromise in survival or recurrence rates (9). This is particularly significant for patients with larger tumors or unfavorable tumor-to-breast size ratios, where traditional BCS is often not feasible.

Conclusions

The evidence supporting BCS and OBCS as preferred surgical options over mastectomy, when feasible, is robust. However, their widespread adoption requires standardized oncoplastic training programs, improved access to expertise, and enhanced patient education. Mastectomy remains the preferred option for risk-reducing surgery in patients with pathogenic high-penetrance genes and for those with extensive or multicentric disease not amenable to extreme OBCS.

The shift toward BCS reflects a broader trend in oncology: prioritizing approaches that maximize patient outcomes while minimizing physical and psychological morbidity. The studies discussed here provide compelling evidence that BCS, particularly when combined with oncoplastic techniques, is not only oncologically safe but also associated with superior survival outcomes and improved quality of life. Nonetheless, clinicians should be mindful of a holistic view of the patient’s needs and self-image may be more critical in oncoplastic reconstruction than just reconstructed mammary volume (10).

As the surgical landscape evolves, clinicians must embrace these advancements and prioritize patient-centered care. Once considered a compromise, BCS has now become the gold standard in breast cancer treatment. Modern oncoplastic techniques have expanded their applicability to most early breast cancer patients, establishing a new benchmark in breast cancer management. In the future, AI-assisted preoperative planning will further enhance both precision and cosmetic outcomes in OBCS (11).

Acknowledgments

The authors express their gratitude to Breast Cancer Hope Charity, Jocelyn Rosenberg, and her late husband, Michael Rosenberg, for their support of their research program.

Footnote

Provenance and Peer Review: This article was a standard submission to the journal. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2024-572/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2024-572/coif). K.M. has received consulting fees from QMedical and received honoraria for offering academic and clinical advice to Merit Medical. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347:1227-32. [Crossref] [PubMed]
2. Mokbel K. Unlocking the Power of the Homing Phenomenon: Why Breast Conserving Surgery Outshines Mastectomy in Overall Survival. Clin Breast Cancer 2024;24:85-92. [Crossref] [PubMed]
3. De la Cruz Ku G, Karamchandani M, Chambergo-Michilot D, et al. Does Breast-Conserving Surgery with Radiotherapy have a Better Survival than Mastectomy? A Meta-Analysis of More than 1,500,000 Patients. Ann Surg Oncol 2022;29:6163-88. [Crossref] [PubMed]
4. Tollan CJ, Pantiora E, Valachis A, et al. A Systematic Review and Meta-Analysis on the Role of Repeat Breast-Conserving Surgery for the Management of Ipsilateral Breast Cancer Recurrence. Ann Surg Oncol 2022;29:6440-53. [Crossref] [PubMed]
5. Clough KB, Soussaline M, Campana F, et al. Mammoplasty combined with irradiation: conservative treatment of breast cancer localized in the lower quadrant. Ann Chir Plast Esthet 1990;35:117-22. [PubMed]
6. Salibian AA, Olson B, Shauly O, et al. Oncoplastic breast reconstruction: Principles, current techniques, and future directions. J Surg Oncol 2022;126:450-9. [Crossref] [PubMed]
7. Davies C, Johnson L, Conefrey C, et al. Clinical and patient-reported outcomes in women offered oncoplastic breast-conserving surgery as an alternative to mastectomy: ANTHEM multicentre prospective cohort study. Br J Surg 2024;112:znae306. [Crossref] [PubMed]
8. Wazir U, El Hage Chehade H, Headon H, et al. Oncological Safety of Lipofilling in Patients with Breast Cancer: A Meta-analysis and Update on Clinical Practice. Anticancer Res 2016;36:4521-8. [Crossref] [PubMed]
9. Kosasih S, Tayeh S, Mokbel K, et al. Is oncoplastic breast conserving surgery oncologically safe? A meta-analysis of 18,103 patients. Am J Surg 2020;220:385-92. [Crossref] [PubMed]
10. Raposio E, Belgrano V, Santi P, et al. Which is the Ideal Breast Size?: Some Social Clues for Plastic Surgeons. Ann Plast Surg 2016;76:340-5. [Crossref] [PubMed]
11. Mennati M, Moeinafshar A, Rezaei N. Enhancing breast cancer surgery outcomes: A comprehensive review of oncoplastic techniques, surgical planning, and aesthetic considerations. Crit Rev Oncol Hematol 2025;206:104578. [Crossref] [PubMed]