Patient reported outcomes following breast conserving surgery are improved by minimizing re-excisions and excessive breast tissue removal

  • Chris Baliski
    Corresponding author. BC Cancer – Kelowna, Dept. of Surgical Oncology, 399 Royal Avenue, Kelowna, British Columbia, V1Y 5L3, Canada.
    BC Cancer – Kelowna, Dept. of Surgical Oncology, University of British Columbia Okanagan, Dept. of Surgery, Kelowna General Hospital, Kelowna, BC, Canada
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  • Brendan Bakos
    Cancer Surveillance and Outcomes, BC Cancer, Vancouver, BC, Canada
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      • Patient reported outcomes (PRO) allow patients' perception of health care to be evaluated.
      • Understanding factors impacting PRO's that are within the control of the surgeons are essential to improve outcomes.
      • The volume of tissue removed during breast conservation surgery, as well as the need for re-excision impact PRO's.
      • The negative impact of re-excisions of PRO's supports their consideration as a quality measure in the performance of breast conservation surgery.
      • Satisfaction with breast, and psychological and physical well-being of the chest are negatively affected by the volume of breast tissue removed.



      Patient reported outcomes (PRO's) are a valuable tool in obtaining the patients' perspective on the effectiveness of breast conservation surgery. Investigation has primarily been focused on patient and disease related factors impacting PRO's, with a limited focus on surgically modifiable factors. We investigate the impact that the volume of breast tissue removed, and performance of re-excisions have on PRO's.


      Retrospective evaluation of the BREAST-Q (breast conservation module) in patients undergoing breast conserving surgery over a 3 year period. Multivariate analysis of patient, disease, and treatment related factors impacting PRO's.


      163 patients completed the BREAST-Q. The median satisfaction with breast score was 67 (IQR, 48–88). Increasing volume of resected breast tissue was negatively associated with appearance of the breast (−0.05/cm3 (CI; −0.08 to −0.01)), as was the performance of re-excisions (−6.59 (CI; −14.73 – 0)). Physical well-being of chest was negatively associated with the volume of breast tissue removed (−0.05/cm3 (CI; −0.08 – 0)), but not re-excisions. Psychosocial well-being was negatively affected by the volume of tissue removed ((-0.04/cm3(CI; −0.07 – 0)), and re-excisions (−2.88 (CI; −10.96 – 0)). Patient body mass index, disease stage, receipt of Tamoxifen, as well as axillary lymph node dissection also impacted BREAST-Q domain scores.


      The removal of larger volumes of breast tissue and performance of re-excisions negatively impact patient quality of life and breast satisfaction following breast conserving surgery. Optimal patient reported outcomes are associated with accurate tumour removal, which minimizes re-excisions and the removal of normal breast tissue.
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        • Javid S.H.
        • Lawrence S.O.
        • Lavallee D.C.
        Prioritizing Patient‐Reported outcomes in breast cancer surgery quality improvement.
        Breast J. 2017; 23: 127-137
        • Atisha D.
        • Atisha D.
        • Rushing C.
        • et al.
        A national snapshot of satisfaction with breast cancer procedures.
        Ann Surg Oncol. 2015; 22: 361-369
        • Jay M.
        • Creelman B.
        • Baliski C.
        Patient reported outcomes associated with surgical intervention for breast cancer.
        Am J Surg. 2019; (S0002-9610(18)31307-2 [pii])
        • Pusic A.L.
        • Matros E.
        • Fine N.
        • et al.
        Patient-reported outcomes 1 year after immediate breast reconstruction: results of the mastectomy reconstruction outcomes consortium study.
        J Clin Oncol : off J Am Soc Clin Oncol. 2017; 35: 2499-2506
        • Klassen A.F.
        • Dominici L.
        • Fuzesi S.
        • et al.
        Development and validation of the BREAST-Q breast-conserving therapy module.
        Ann Surg Oncol. 2020;
        • Cano S.J.
        • Klassen
        • Anne F.
        • Scott A.M.
        • Pusic
        • Andrea L.
        A closer look at the BREAST-Q.
        Clin Plast Surg. 2013; 40: 287-296
        • Baliski C.
        • Hughes L.
        • Bakos B.
        Lowering re-excision rates after breast-conserving surgery: unraveling the intersection between surgeon case volumes and techniques.
        Ann Surg Oncol. 2020;
        • Krekel N.M.A.
        • Zonderhuis B.
        • Muller S.
        • et al.
        Excessive resections in breast-conserving surgery A retrospective multicentre study.
        Breast J. 2011; 17: 602-609
        • Landercasper J.
        • Attai D.
        • Atisha D.
        • et al.
        Toolbox to reduce lumpectomy reoperations and improve cosmetic outcome in breast cancer patients: the american society of breast surgeons consensus conference.
        Ann Surg Oncol. 2015; 22: 3174-3183
        • Pataky R.E.
        • Baliski C.R.
        Reoperation costs in attempted breast-conserving surgery: a decision analysis.
        Curr Oncol. 2016; 23: 314-321
        • Vrouwe S.Q.
        • Somogyi R.B.
        • Snell L.
        • McMillan C.
        • Vesprini D.
        • Lipa J.E.
        Patient-reported outcomes following breast conservation therapy and barriers to referral for partial breast reconstruction.
        Plast Reconstr Surg. 2018; 141 ([doi]): 1-9
        • Haloua M.H.
        • Volders J.H.
        • Krekel - Taminiau N.
        • et al.
        Intraoperative ultrasound guidance in breast-conserving surgery improves cosmetic outcomes and patient satisfaction: results of a multicenter randomized controlled trial (COBALT).
        Ann Surg Oncol. 2016; 23: 30-37
        • Ojala K.
        • Meretoja
        • Tuomo J.
        • Leidenius
        • Marjut H.K.
        Aesthetic and functional outcome after breast conserving surgery – comparison between conventional and oncoplastic resection.
        Eur J Surg Oncol. 2016; 43: 658-664
        • Volders J.H.
        • Negenborn V.L.
        • Haloua M.H.
        • et al.
        Breast-specific factors determine cosmetic outcome and patient satisfaction after breast-conserving therapy: results from the randomized COBALT study.
        J Surg Oncol. 2018; 117: 1001-1008
        • Foersterling E.
        • Golatta M.
        • Hennigs A.
        • et al.
        Predictors of early poor aesthetic outcome after breast‐conserving surgery in patients with breast cancer: initial results of a prospective cohort study at a single institution.
        J Surg Oncol. 2014; 110: 801-806
        • Gardfjell A.
        • Dahlbäck C.
        • Åhsberg K.
        Patient satisfaction after unilateral oncoplastic volume displacement surgery for breast cancer, evaluated with the BREAST-Q.
        World J Surg Oncol. 2019; 17: 96
        • O'Connell R.
        • DiMicco R.
        • Khabra K.
        • et al.
        Initial experience of the BREAST-Q breast-conserving therapy module.
        Breast Cancer Res Treat. 2016; 160: 79-89
        • Hughes L.
        • Hamm J.
        • McGahan C.
        • Baliski C.
        Surgeon volume, patient age, and tumor-related factors influence the need for re-excision after breast-conserving surgery.
        Ann Surg Oncol. 2016; 23: 656-664
        • Dahlbäck C.
        • Manjer J.
        • Rehn M.
        • Ringberg A.
        Determinants for patient satisfaction regarding aesthetic outcome and skin sensitivity after breast-conserving surgery.
        World J Surg Oncol. 2016; 14: 303
        • Heil J.
        • Heil J.
        • Breitkreuz K.
        • et al.
        Do reexcisions impair aesthetic outcome in breast conservation surgery? exploratory analysis of a prospective cohort study.
        Ann Surg Oncol. 2012; 19: 541-547
        • Hau E.
        • Browne L.H.
        • Khanna S.
        • et al.
        Radiotherapy breast boost with reduced whole-breast dose is associated with improved cosmesis: the results of a comprehensive assessment from the st. george and wollongong randomized breast boost trial.
        Int J Radiat Oncol Biol Phys. 2012; 82: 682-689
        • Hill-Kayser C.E.
        • Chacko D.
        • Hwang W.
        • Vapiwala N.
        • Solin L.J.
        Long-term clinical and cosmetic outcomes after breast conservation treatment for women with early-stage breast carcinoma according to the type of breast boost.
        Int J Radiat Oncol Biol Phys. 2011; 79: 1048-1054
        • Hawley S.T.
        • Li Y.
        • An L.C.
        • et al.
        Improving breast cancer surgical treatment decision making: the iCanDecide randomized clinical trial.
        J Clin Oncol : off J Am Soc Clin Oncol. 2018; 36: 659-666
        • Flanagan M.
        • Zabor E.
        • Romanoff A.
        • et al.
        A comparison of patient-reported outcomes after breast-conserving surgery and mastectomy with implant breast reconstruction.
        Ann Surg Oncol. 2019; 26: 3133-3140
        • Lagendijk M.
        • Egdom L.S.E.
        • Veen F.E.E.
        • et al.
        Patient-reported outcome measures may add value in breast cancer surgery.
        Ann Surg Oncol. 2018; 25: 3563-3571
        • Rose M.
        • Svensson H.
        • Handler J.
        • Hoyer U.
        • Ringberg A.
        • Manjer J.
        Patient-reported outcome after oncoplastic breast surgery compared with conventional breast-conserving surgery in breast cancer.
        Breast Cancer Res Treat. 2020; 180: 247-256
        • Krekel N.M.
        • Haloua M.H.
        • Cardozo Lopes
        • Alexander M.F.
        • et al.
        Intraoperative ultrasound guidance for palpable breast cancer excision (COBALT trial): a multicentre, randomised controlled trial.
        Lancet Oncol. 2013; 14: 48-54
        • Pukancsik D.
        • Kelemen P.
        • Ujhelyi M.
        • et al.
        Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: an aesthetic and functional prospective cohort study.
        Eur J Surg Oncol. 2017; 43 (S0748-7983(16)31004-6) ([pii]): 303-310
        • Di Micco R.
        • O'Connell R.L.
        • Barry P.A.
        • Roche N.
        • MacNeill F.A.
        • Rusby J.E.
        Standard wide local excision or bilateral reduction mammoplasty in large-breasted women with small tumours: surgical and patient-reported outcomes.
        Eur J Surg Oncol. 2016; 43 (10.1016/j.ejso.2016.10.027): 636-641
        • Voineskos S.
        • Klassen A.
        • Cano S.
        • Pusic A.
        • Gibbons C.
        Giving meaning to differences in BREAST-Q scores: minimal important difference for breast reconstruction patients.
        Plast Reconstr Surg. 2020; 145: 11e-20e
        • Eriksson L.
        • He W.
        • Eriksson M.
        • et al.
        Adjuvant therapy and mammographic density changes in women with breast cancer.
        JNCI Cancer Spectr. 2018; 2: pky071
        • Vrieling C.
        • Collette L.
        • Fourquet A.
        • et al.
        The influence of the boost in breast-conserving therapy on cosmetic outcome in the EORTC "boost versus no boost" trial. EORTC radiotherapy and breast cancer cooperative groups. european organization for research and treatment of cancer.
        Int J Radiat Oncol Biol Phys. 1999; 45 (S0360301699002114) ([pii]): 677-685
        • Olivotto I.
        Late cosmetic outcome after conservative surgery and radiotherapy: analysis of causes of cosmetic failure.
        Int J Radiat Oncol Biol Phys. 1989;
        • Olivotto I.
        • Whelan T.
        Interim cosmetic and toxicity results from RAPID: a randomized trial of accelerated partial breast irradiation using three-dimensional conformal external beam radiation.
        J Clin Oncol. 2013;
        • Lagendijk M.
        • van Egdom L.S.E.
        • Richel C.
        • et al.
        Patient reported outcome measures in breast cancer patients.
        Eur J Surg Oncol. 2018; 44: 963-968
        • Ashikaga T.
        • Krag D.N.
        • Land S.R.
        • et al.
        Morbidity results from the NSABP B‐32 trial comparing sentinel lymph node dissection versus axillary dissection.
        J Surg Oncol. 2010; 102 (10.1002/jso.21535): 111-118