Guidelines for oncoplastic breast reconstruction

Abstract

161Breast reconstruction and oncoplastic techniques have been widely adopted in the surgical management of patients with breast cancer. The National Mastectomy and Breast Reconstruction Audit (NMBRA) 1 is the largest prospective audit of breast reconstruction ever carried out. It was designed and implemented by the Clinical Effectiveness Unit at The Royal College of Surgeons of England with input from the Association of Breast Surgery (ABS), the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), and the Royal College of Nursing. The NMBRA examined a broad range of clinical and patient reported outcomes in more than 18,000 women. Factors examined included patient information and access to reconstructive services as well as the level of pain, complications, quality of life and wellbeing after surgery.The patient reported outcomes in the NMBRA highlight the positive effects of breast reconstruction on quality of life and the very high levels of satisfaction with the clinical care provided. The audit did, however, find complication rates, levels of postoperative pain and readmission rates that were much higher than expected. There were also variations in preoperative provision of information, access to services and some clinical outcomes.The original ABS guidelines 2 predated the NMBRA. One of the key recommendations of the audit was that new guid-ance should be written that describes 'best practice' and sets current standards of care. Following this, a multidisciplinary writing group of specialists with expertise in the management of patients undergoing oncoplastic procedures was set up by the ABS and BAPRAS to develop comprehensive new guidelines: Oncoplastic Breast Reconstruction: Guidelines for Best Practice. 3 A patient representative was involved throughout as a core member of the group. Feedback from a wide range of stakeholders has been incorporated into the document, which enjoys the support of Professor Sir Mike Richards, the National Cancer Director. The guidelines are available on the ABS and BAPRAS websites.The NMBRA identified more than 80 unique metrics, reflecting previously undisclosed standards of care. These provided a benchmark for the selection and development of 25 new quality criteria, which form the backbone of the new guidelines (Table 1). The quality criteria were selected to be outcome based, measurable and clinically relevant. They set standards that can be used for future audits, within individual units or nationally.Since oncoplastic breast surgery is a developing area of clinical practice with a limited evidence base, the guidance reflects a combination of peer opinion and the best available evidence informed by peer reviewed publications. External advice was commissioned on pain management from

Oncoplastic Surgery: Pushing the Limits of Breast-Conserving Surgery

“…In France, two pioneers, Jean‐Yves Petit and Krishna Clough , developed multiple OPS techniques and trained many surgeons (France has been one of the leading countries in OPS). They were quickly followed by British surgeons who created a curriculum of graduate oncoplastic surgeons . In Europe, OPS was only widely accepted and integrated in the last decade.…”

Adherence to best practice consensus guidelines for implant-based breast reconstruction: Results from the iBRA national practice questionnaire survey

“…They covered all types of breast reconstruction and included recommendations for each stage of the clinical pathway from diagnosis to post-operative follow-up. The guidelines included 25 quality criteria (QC) and were proposed as a standardized ‘framework that should be used to assess current practice and deliver high quality care’ [7].…”

“To clip or not to clip. That is no question!”

“…Whilst many surgeons now do this, there are no generally accepted guidelines in widespread use across Europe, which impairs RT targeting. Even in countries such as the UK and The Netherlands, where adoption of oncoplastic techniques is very advanced and formal training and/or guidelines are available, these guidelines mention multidisciplinary work but make no reference to the application of clips into BCS cavities let alone specify how they should be placed 12,13 . In summary , we propose the following recommendations be adopted by breast surgeons and radiation oncologists:…”

“…Breast surgeons should follow the GEC ESTRO guidelines for the positioning of surgical clips [12,13]. This would ensure optimal multidisciplinary collaboration and optimal targeted treatment in the modern era of breast conservation.…”