Siobhan Laws

The impact of providing an oncoplastic service on the workload of a specialist breast unit.

Abstract:  Increasing breast specialization triggered a review of our surgical activity. All 10,000 elective inpatient and day case procedures between 1998 and 2008 were grouped into six categories: oncological, primary, secondary and revisional oncoplastic, and other breast and nonbreast procedures. Overall, surgical activity increased, with a rise in breast and a fall in nonbreast procedures, as a result of a changing caseload in each category (chi‐squared for linear trend = 55.24: p < 0.00001). These included increases in oncological procedures, secondary oncoplastic, and revisional oncoplastic procedures. Increased oncoplastic activity was associated with a reduction in other breast procedures (chi‐squared for linear trend = 04.94: p < 0.00001). The impact of breast specialization reported in the 1990′s has accelerated with the introduction of oncoplastic surgery. This has major short‐term and long‐term implications when planning a modern breast service.

Is IORT ready for roll-out?

Two large randomised controlled trials of intraoperative radiotherapy (IORT) in breast-conserving surgery (TARGIT-A and ELIOT) have been published 14 years after their launch. Neither the TARGIT-A trial nor the ELIOT trial results have changed the current clinical practice for the use of IORT. The in-breast local recurrence rate (LRR) after IORT met the pre-specified non-inferiority margins in both trials and was 3.3% in TARGIT-A and 4.4% in the ELIOT trial. In both trials, the pre-specified estimates for local recurrence (LR) with external beam radiation therapy (EBRT) significantly overestimated actual LRR. In the TARGIT-A trial, LR with EBRT was estimated at the outset to be 6%, and in the ELIOT trial, it was estimated to be 3%. Surprisingly, LRR in the EBRT groups has been found to be significantly lower, 1.3% in the EBRT arm of the TARGIT-A and 0.4% in the EBRT arm of the ELIOT trial, respectively. Median follow-up was 2.4 years for the TARGIT-A trial and 5.8 years for the ELIOT trial. However, the initial cohort of patients in the TARGIT-A trial (reported in 2010) now have a median follow-up of 3.8 years and data on LR were available at 5 years follow-up on 35% of patients (18% who received IORT). Although further follow-up will increase confidence with the data, it will also further delay clinical implementation. By carefully weighing the risks and benefits of a single-fraction radiation treatment with patients, IORT should be offered within agreed and strict protocols. Patients deemed at low risk of LR or those deemed suitable for partial breast irradiation, according to the GEC-ESTRO and ASTRO recommendations, could be considered as candidates for IORT. These guidelines apply to all partial breast irradiation techniques, and more specific guidelines for IORT would assist clinicians.