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Oncoplastic in a Pre-Paradigm Era: A Brazilian Perspective in an American Problem

2010; Lippincott Williams & Wilkins; Volume: 125; Issue: 6 Linguagem: Inglês

10.1097/prs.0b013e3181cb61d5

1529-4242

Cícero Úrban,

Breast Cancer Treatment Studies

Sir: Plastic surgeons are pioneers and have undeniable leadership in the field of breast reconstruction. We think that this new scenario of oncoplastic surgeons or breast surgeons doing reconstruction will not modify it. On the contrary, it can be a way not only to improve oncologic and aesthetic results in breast-conserving surgery but also to increase the availability of breast reconstruction to more breast cancer patients. The controversy of whether breast surgeons or plastic surgeons should perform breast reconstruction is present in many countries. In Brazil it is no different, although most of the great centers have both breast and plastic surgeons working together in all cases of reconstruction. The scenario is not the same all over the country, however, and it depends on many problems similar to the ones that are very well described in Losken and Nahabedian's article.1 Today, many Brazilian breast surgeons are unable to offer immediate breast reconstruction to many of their patients due to the unavailability of plastic surgeons to help them with it. Of course, it is not a matter of qualification of our plastic surgeons, since we have one of the best schools of plastic surgery. Low-income, time-consuming surgery, an extended postoperative period, and more surgical complications than aesthetic surgery are some of the reasons that can explain our reality. There are three important facts to be considered in the U.S. decision. The first one is that most breast cancer patients in the world do not receive any kind of breast reconstruction, and unfortunately, the United States is not excluded from this sad reality. The second one is that immediate breast reconstruction has better oncologic results in terms of margins in breast-conserving surgery, lower index of re-excisions, and a better local control of disease and positive results regarding radiotherapy planning, particularly for gigantomastia.2–6 Moreover, immediate breast reconstruction has better aesthetic results than delayed reconstruction after mastectomy. The third fact, and perhaps the most important of them all, is that patients with pronounced asymmetry are more likely to feel significantly stigmatized with breast cancer treatment. They have more fear of death caused by breast cancer, increased psychosocial problems due to loss of their femininity, more depressive symptoms, and, consequently, more harm to their quality of life, even in cases of early breast cancer, which can correspond to better chances of cure.7 Due to these points, we believe that this new arrangement is perfectly well justified. The creation of a "new" specialist breast surgeon who performs reconstructions–-the so called oncoplastic surgeon–-has innate advantages. Of course, a single surgeon with both oncologic and reconstructive backgrounds requires special training in cross-specialty techniques to undertake all of these procedures at the highest standard.3,8,9 So, from our point of view, the question does not refer only to whether it is appropriate to accept that U.S. breast surgeons can or cannot perform reconstructive surgery, the way it happens in other countries, as pointed out by Canady et al.10 in the same issue of the Journal. As specialists, breast surgeons should always consider in all procedures the breast as both an aesthetic and a functional organ. Even for those breast surgeons who work together with plastic surgeons, they could perform best-quality operations if they have broader skills in techniques related to plastic surgery of the breast. The real point to consider, regardless of the country in which one practices, is that it is time to set limits for this provoking, growing field of a "new" subspecialty. The question is not who can do it but how to do it to reach the most breast cancer patients with the highest quality. In fact, we are in the pre-paradigm era in oncoplastic surgery. Philosophers of science describe this intriguing period as a period of unclear limits of a new field of knowledge. In our view, both societies, following the example of the United Kingdom, can work together, in strict collaboration, and propose a more appropriate model for U.S. reality.11 In Brazil, we are working to do that too, but as all of us know very well that it is hard to change from a pre-paradigm to a paradigm era.9 Plastic surgeons will maintain their leadership in the breast reconstruction field. The aim is not to substitute plastic surgeons with the "new" oncoplastic surgeons. Breast surgeons used to work in multidisciplinary teams, and in general, they like to work together with plastic surgeons to shorten their surgical time and to share responsibilities. Moreover, plastic surgeons could be oncoplastic surgeons too, if they want to. The real facility posed by this model is to expand breast reconstruction to be available to the most breast cancer patients and not to limit these procedures only to big centers. After all, breast cancer is a major public health problem, and the classic model of "breast surgeon–plastic surgeon working together on all cases" works very well, but it is clearly not enough to resolve a disease with such a complex dimension. We recently developed a new classification for oncoplastic surgery procedures, already published, to help with this new scenario. It is a classification based on competencies in breast reconstructive techniques, inspired by many rounds at the Brazilian Breast Society, where we have an increasing demand for training in oncoplastic techniques.8 We consider three distinct competencies in this classification: Class I: monolateral breast reconstruction techniques such as aesthetic skin incisions, de-epithelization of the areolar margins, glandular mobilization and reshaping techniques, purse-string sutures for central quadrant reconstruction, and immediate breast reconstruction with temporary expanders. Specific competence in plastic surgery is not required at this point. Class II: bilateral procedures such as immediate and delayed breast reconstruction with implants, lipofilling, breast augmentation, breast reduction, mastopexy, Grisotti flap, and nipple and areola reconstruction. Specific competence in plastic surgery techniques of the breast is required to achieve better symmetry. Class III: more complex monolateral or bilateral procedures involving autologous flaps (pedicled or free flaps) or a combination of techniques. A higher standard in plastic surgery techniques is required. Since most breast cancer patients need class I or II techniques, our suggestion is that it is necessary to conduct the surgical training of oncoplastic surgeons mainly in these competencies. Class III competencies could be optional. In this way, not all breast surgeons need to have skills in class III, but all of them should be well trained in class I and II competencies. We think that the oncoplastic surgery concept and philosophy of work are already consolidated and they are expanding their frontiers. This advance is now becoming the standard practice in many places in Europe, Asia, Oceania, and Latin America. The United States cannot be left out of this trend. Cicero A. Urban, M.D., Ph.D. Breast Unit Hospital Nossa Senhora das Graças Department of Bioethics and Scientific Methodology Positivo University Medical and Dentistry School Curitiba, Brazil [email protected]