Communication Is ‘Key’ for Successful Oncoplastic Surgery in Breast Cancer

Roshani Patel, MD, FACS

Hackensack Meridian Health

Performing oncoplastic surgery may have a “tremendous impact” psychologically on patients with breast cancer, which may include a reduction in cosmetic defect following surgery and decreases in chronic neck and back pain, according to Roshani Patel, MD, FACS.

Patel, a board-certified breast surgical oncologist at Hackensack Meridian Health and the medical director for breast surgery at Jersey Shore University Medical Center, spoke with CancerNetwork^® about the evolution of oncoplastic breast surgery from her perspective, emphasizing the procedure as a cohesive effort in managing patient tumors and cosmetic outcomes. On top of the teamwork required between breast and plastic surgeons, the surgery often encompasses communication with radiologists and pathologists when defining tumor margins to yield optimal outcomes for patients.

“What I need to emphasize is that to be successful with this procedure, you really need to be a cohesive team with everybody who’s involved,” Patel said. “There is a lot of breast surgeons who will do these procedures on their own…. I just prefer to have my plastic surgeons around with me because sometimes we have to think outside of the box with some of the more complicated procedures that we do together. But at the end of the day, I think that communication is key.”

According to Patel, other benefits associated with the oncoplastic surgical procedure may include a reduction in the amount of radiation needed to be administered to the patient, thereby yielding less scarring and pain near the resected area. She also described her preference for performing oncoplastic procedures alongside her plastic surgeons rather than having the resection and plastic surgery portions performed separately.

CancerNetwork^®: Could you discuss how oncoplastic surgery is performed?

Patel: Oncoplastic procedure is done with a breast surgeon in conjunction with or without a plastic surgeon. For patients who may have larger breast tissue or breast tissue that tends to droop as they get older, this enables us to create a lifted procedure. Patients can have the tumor removed, and then they can essentially get a lift, which involves some form of rearranging the breast tissue. A lot of us do these procedures in conjunction with a plastic surgeon.

How has this procedure evolved over the last decade or so?

When I was doing my fellowship training in 2009, there were very few surgeons who were performing this procedure. Sometimes we had the challenge of patients who may have had a larger area of breast tissue with a larger tumor that may need to be removed. When we did the surgery, everything looked fine; we took the tumor out, but sometimes patients may have had additional treatments in the form of radiation. This would result in a significant cosmetic defect. Alternatively, patients may have had a small tumor in larger breasts, and unfortunately, after the radiation, they developed swelling in their breast. Some of these patients may have had chronic neck and back pain.

What we found is by combining the removal of the tumor with a breast reduction, lift, or tissue rearrangement procedure, it reduces the cosmetic changes that we see with the subsequent radiation. Also, the chronic neck and back pain can go away.

Could you speak to the benefit that this procedure provides patients from a physical or psychological perspective?

There’s definitely a psychological benefit. Every single one of my patients who underwent this procedure had wanted breast reductions for a long time or something to help the breast look a little bit better or more [suitable] for their frame. Oftentimes, we’re using the incisions that we use for the breast reduction. Rather than seeing an incision that reminds them of where their breast cancer was, after seeing breasts that look new to them, they no longer have any chronic neck and back pain. They feel like they have a normal breast size relative for their body frame. It has had a tremendous impact for these patients.

We always talk to patients about having a small margin of healthy breast tissue around the [resection site] per guidelines, but oftentimes we’re getting a huge, healthy rim of breast tissue around these tumors. It has affected how our radiation oncologists approach the radiation planning because a lot of times patients may need a boost dose to the area where the cancer was. Typically, we’ll leave clips in where the cancer was used to help the radiation oncologist plan their field. But we’re finding that patients may need less of a boost or less intense radiation because we’re getting such good margins around the tumor bed, which means that there’s going to be less scarring and pain after they have their radiation. They are also having some improvement in their adverse effect symptoms.

Could you speak a bit to the importance of having a multidisciplinary care team for this procedure?

This is a procedure that requires everybody to step outside of their comfort zone. I have personally taken oncoplastic classes and attended Zoom sessions online during the COVID-19 pandemic. It’s important for me to understand how the plastic surgeons need to plan the incision pattern.

We have to communicate with each other because they have to plan how the blood flow is going to get to the nipple in order to preserve it. The surgeons also have to understand the tumor biology. All my plastic surgeons that I do these procedures with regularly attend the tumor boards. During those cases, we all review the films. I’ll often draw out a diagram for the patient, explaining to them where everything is and how the plastic surgeon is planning their incision.

We also communicate with the radiologists ahead of time and let them know that we are taking out a rather large specimen. In addition, there have been cases that were not as straightforward. In that case, I’ll draw a diagram and send it to the pathologist so that way they know we have a good margin or that there’s anything that we’re worried about. Basically, both surgical teams, pathology, and radiology have to work very closely together to make sure that everything goes smoothly for these patients.

What do you feel that your colleagues should take away from this conversation?

There have been some controversies about whether to go in and do the surgical oncology procedure first and then have the plastic surgery part done. There are pros and cons of doing either first. I can go in and remove the tumor, but at the end of the day, we have to orient the specimens that we take out. I find it easier to be there with the plastic surgeons when I’m doing the surgery so that we can mark everything out and send it to pathology and draw whatever we need to, rather than do the procedure separately. Sometimes we take the tumor out with a patient’s reduction specimen as one specimen and map everything out. I’m also putting clips in as we take everything out in case I need to go in to remove an additional piece.

We can argue back and forth about whether you take the cancer out and then go back in [for plastic surgery]. When I talk to patients, I tell them that there’s nothing wrong with either procedure. There are pros and cons to both, but I feel that I can generally get a wider margin of breast tissue, which is more accurate for the pathologist, when we take everything out together.