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The Breast 19 (2010) 437e438

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The Breast

journal homepage: www.elsevier .com/brst

Editorial

Oncoplastic surgery: “A rolling stone gathers no moss”

When I was in my first residency year for general surgery inAustria 1999, the word “oncoplastic”was unpresentable at nationalmeetings. Ten years and a couple of international breast cancermeetings later we have books about oncoplastic surgery andsome countries even developed fellowship programs for oncoplas-tic surgery, some are planning to do so. What happened?

Modern oncoplastic techniques for volume displacement duringbreast conservation1 helped to pave the way for the word “onco-plastic” from some single centers’ to the worldwide medicalcommunities’ vocabulary. This third option for breast surgeonsbeneath mastectomy and traditional breast conservation usesmethods of breast reduction to improve cosmesis of breastconserving surgery during one-stage operation. This, among otherthings, increased the attractiveness for younger surgeons to startspecializing in breast cancer surgery. However, the road to strikeattention to these new techniques is still long, but “a rolling stonegathers no moss”.

The first way to inaugurate new surgical techniques is to strikeattention through clinical trials and lectures at national and inter-national meetings. This happened throughout the last years dueto breast cancer meeting such as the Milan meeting or the EBCC(I can still remember the fifth EBCC at Nice in 2006 where KrishnaClough was invited to present his results of more than 200 patientsafter oncoplastic surgery with volume displacement.2 The localmeeting committee did not expect such a run on this lecture andthe small room was packed with hundreds of people). The secondstep to inaugurate a new technique after striking attention is toprovide education. And this is where we are.

The article by Joao Cardoso and Dick Rainsbury in the presentissue of this journal is an important contribution to bring oncoplas-tic training closer to surgical fellows (andwhen I talk about surgicalfellows I mean General Surgeons, Gynecologists and Plastic andReconstructive Surgeons). During the 7th Portuguese SenologyCongress in Vilamoura in 2009 Joao Cardoso gathered some ofthe leading specialists for oncoplastic surgery in order to makea consensus statement about training for oncoplastic surgery.Surgeons from different countries such as Spain, Portugal, Braziland the United Kingdom talked about their fellowship programsand discussed the main issues regarding oncoplastic surgerytraining. A statement has been made with the final conclusionthat “. increasing the availability of oncoplastic breast surgery isa major challenge, which demands much closer collaboration andcooperation between breast and plastic surgeons, backed up bynew training schemes, new curricula and new guidelines”.

From this article it further becomes clear that the UnitedKingdom has the most professional program so far and it helped

0960-9776/$ e see front matter � 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.breast.2010.03.027

to increase the “recruiting rate” for breast surgeons in the UK asthis branch of general surgery was “. an unpopular career option”.In fact the “recruitment crisis” within the general surgical commu-nity regarding specializing in breast cancer may be a problem forthe future in several other countries, too. Fellowship programs foroncoplastic surgery may be a way out of this crisis. But how shouldthey look like?

Although I doubt that it is possible to have similar fellowshipprograms indifferent countries, Imiss future aspects andsuggestionsfrom the symposium, how such programs may look like. I think it isnecessary that national guidelines have to be established. Withoutthe help of the government this improvement in breast cancer treat-ment will never develop. Moreover, as General Surgeons, Gynecolo-gists as well as Plastic and Reconstructive Surgeons may becomebreast fellows it is necessary to develop a program for all threesurgical groups. The following questions should be raised:

Which department(s) may initiate a fellowship program?How long should the duration of such a fellowship be?Shall we develop European or even worldwide fellowship programguidelines?Who may be trained?Who should pay for the education?Should oncoplastic techniques be incorporated into a generalbreast cancer fellowship program or should they be integrated intheir own fellowship?

To answer some of the above question, I think that Europeanwide fellowship programs should be developed with the help oflocal breast cancer societies. The EUSOMA may be a very goodsociety to guide this process. Oncoplastic surgery should be incor-porated within a clinical breast cancer fellowship and it shouldlast 2 years. Only breast cancer centers with high volume (at least150/year) should be allowed to have such fellowship programsand the EU should pay for this education.

In the meantime we have to further assess the benefits3 andrisks4 of oncoplastic surgery in prospective trials and retrospectiveanalyses. There are only limited data providing evidence for animproved cosmetic outcome5 with similar oncologic results.1

However, others documented an increased number of postopera-tive breast biopsies after oncoplastic procedures.4 Thus, we needto start prospective trials and document all oncoplastic procedures,may be with an international database, e.g. with the help fromEUSOMA, to have better clinical retrospective data. Moreover,fellowships may in part be used to increase the number of urgentlyneeded prospective clinical trials.

Editorial / The Breast 19 (2010) 437e438438

References

1. FitzalF,NehrerG,DeutingerM,etal.Novel strategies inoncoplastic surgery forbreastcancer: immediate partial reconstruction of breast defects. Eur Surg2007;39:330e9.

2. Clough KB. Oncoplastic surgery allows extensive resections for conservativetreatment of breast cancer. Eur J Cancer 2006;4:S119.

3. FitoussiAD, BerryMG, FamaF, et al.Oncoplasticbreast surgery for cancer: analysis of540 consecutive cases [outcomes article]. Plast Reconstr Surg 2010;125(2):454e62.

4. Losken A, Schaefer TG, Newell M, et al. The impact of partial breast reconstruc-tion using reduction techniques on postoperative cancer surveillance. PlastReconstr Surg 2009;124(1):9e17.

5. Fitzal F, Mittlboeck M, Trischler H, et al. Breast-conserving therapy for centrallylocated breast cancer. Ann Surg 2008;247(3):470e6.

Florian Fitzal*Medical University of Vienna,

Department of General Surgery Breast Health Center,Währinger Belt 18-20, 1090 Vienna, Austria

* Tel.: þ431 40400 5621; fax: þ431 40400 5641.E-mail address: florian.fitzal@meduniwien.ac.at

Available online 24 April 2010