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Meta-Analysis
. 2021 Oct 29;10(10):CD013658.
doi: 10.1002/14651858.CD013658.pub2.

Oncoplastic breast-conserving surgery for women with primary breast cancer

Akriti Nanda  1 , Jesse Hu  2 , Sarah Hodgkinson  3 , Sanah Ali  4 , Richard Rainsbury  5 , Pankaj G Roy  6
Affiliations
Meta-Analysis

Oncoplastic breast-conserving surgery for women with primary breast cancer

Akriti Nanda et al. Cochrane Database Syst Rev. .

Abstract

Background: Oncoplastic breast-conserving surgery (O-BCS) involves removing the tumour in the breast and using plastic surgery techniques to reconstruct the breast. The adequacy of published evidence on the safety and efficacy of O-BCS for the treatment of breast cancer compared to other surgical options for breast cancer is still debatable. It is estimated that the local recurrence rate is similar to standard breast-conserving surgery (S-BCS) and also mastectomy, but the aesthetic and patient-reported outcomes may be improved with oncoplastic techniques.

Objectives: Our primary objective was to assess oncological control outcomes following O-BCS compared with other surgical options for women with breast cancer. Our secondary objective was to assess surgical complications, recall rates, need for further surgery to achieve adequate oncological resection, patient satisfaction through patient-reported outcomes, and cosmetic outcomes through objective measures or clinician-reported outcomes.

Search methods: We searched the Cochrane Breast Cancer Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (via OVID), Embase (via OVID), the World Health Organization's International Clinical Trials Registry Platform and ClinicalTrials.gov on 7 August 2020. We did not apply any language restrictions.

Selection criteria: We selected randomised controlled trials (RCTs) and non-randomised comparative studies (cohort and case-control studies). Studies evaluated any O-BCS technique, including volume displacement techniques and partial breast volume replacement techniques compared to any other surgical treatment (partial resection or mastectomy) for the treatment of breast cancer.

Data collection and analysis: Four review authors performed data extraction and resolved disagreements. We used ROBINS-I to assess the risk of bias by outcome. We performed descriptive data analysis and meta-analysis and evaluated the quality of the evidence using GRADE criteria. The outcomes included local recurrence, breast cancer-specific disease-free survival, re-excision rates, complications, recall rates, and patient-reported outcome measures.

Main results: We included 78 non-randomised cohort studies evaluating 178,813 women. Overall, we assessed the risk of bias per outcome as being at serious risk of bias due to confounding; where studies adjusted for confounding, we deemed these at moderate risk. Comparison 1: oncoplastic breast-conserving surgery (O-BCS) versus standard-BCS (S-BCS) The evidence in the review found that O-BCS when compared to S-BCS, may make little or no difference to local recurrence; either when measured as local recurrence-free survival (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.61 to 1.34; 4 studies, 7600 participants; very low-certainty evidence) or local recurrence rate (HR 1.33, 95% CI 0.96 to 1.83; 4 studies, 2433 participants; low-certainty evidence), but the evidence is very uncertain due to most studies not controlling for confounding clinicopathological factors. O-BCS compared to S-BCS may make little to no difference to disease-free survival (HR 1.06, 95% CI 0.89 to 1.26; 7 studies, 5532 participants; low-certainty evidence). O-BCS may reduce the rate of re-excisions needed for oncological resection (risk ratio (RR) 0.76, 95% CI 0.69 to 0.85; 38 studies, 13,341 participants; very low-certainty evidence), but the evidence is very uncertain. O-BCS may increase the number of women who have at least one complication (RR 1.19, 95% CI 1.10 to 1.27; 20 studies, 118,005 participants; very low-certainty evidence) and increase the recall to biopsy rate (RR 2.39, 95% CI 1.67 to 3.42; 6 studies, 715 participants; low-certainty evidence). Meta-analysis was not possible when assessing patient-reported outcomes or cosmetic evaluation; in general, O-BCS reported a similar or more favourable result, however, the evidence is very uncertain due to risk of bias in the measurement methods. Comparison 2: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy alone O-BCS may increase local recurrence-free survival compared to mastectomy but the evidence is very uncertain (HR 0.55, 95% CI 0.34 to 0.91; 2 studies, 4713 participants; very low-certainty evidence). The evidence is very uncertain about the effect of O-BCS on disease-free survival as there were only data from one study. O-BCS may reduce complications compared to mastectomy, but the evidence is very uncertain due to high risk of bias mainly resulting from confounding (RR 0.75, 95% CI 0.67 to 0.83; 4 studies, 4839 participants; very low-certainty evidence). Data on patient-reported outcome measures came from single studies; it was not possible to meta-analyse the data. Comparison 3: oncoplastic breast-conserving surgery (O-BCS) versus mastectomy with reconstruction O-BCS may make little or no difference to local recurrence-free survival (HR 1.37, 95% CI 0.72 to 2.62; 1 study, 3785 participants; very low-certainty evidence) or disease-free survival (HR 0.45, 95% CI 0.09 to 2.22; 1 study, 317 participants; very low-certainty evidence) when compared to mastectomy with reconstruction, but the evidence is very uncertain. O-BCS may reduce the complication rate compared to mastectomy with reconstruction (RR 0.49, 95% CI 0.45 to 0.54; 5 studies, 4973 participants; very low-certainty evidence) but the evidence is very uncertain due to high risk of bias from confounding and inconsistency of results. The evidence is very uncertain for patient-reported outcome measures and cosmetic evaluation.

Authors' conclusions: The evidence is very uncertain regarding oncological outcomes following O-BCS compared to S-BCS, though O-BCS has not been shown to be inferior. O-BCS may result in less need for a second re-excision surgery but may result in more complications and a greater recall rate than S-BCS. It seems that O-BCS may give better patient satisfaction and surgeon rating for the look of the breast, but the evidence for this is of poor quality, and due to lack of numerical data, it was not possible to pool the results of different studies. It seems O-BCS results in fewer complications compared with surgeries involving mastectomy. Based on this review, no certain conclusions can be made to help inform policymakers. The surgical decision for what operation to proceed with should be made jointly between clinician and patient after an appropriate discussion about the risks and benefits of O-BCS personalised to the patient, taking into account clinicopathological factors. This review highlighted the deficiency of well-conducted studies to evaluate efficacy, safety and patient-reported outcomes following O-BCS.

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Conflict of interest statement

Akriti Nanda: none known. Jesse Hu: none known. Sarah Hodgkinson: none known. Sanah Ali: none known Richard Rainsbury: none known. Pankaj Roy: none known.

Figures

1
1
Study flow diagram
2
2
ROBINS‐1 risk of bias for local recurrence
3
3
ROBINS‐1 risk of bias for disease‐free survival
4
4
ROBINS‐1 risk of bias for overall survival
5
5
ROBINS‐1 risk of bias for re‐excisions
6
6
ROBINS‐1 risk of bias for complications
7
7
ROBINS‐1 risk of bias for recall rates
8
8
ROBINS‐1 risk of bias for time to adjuvant therapy
9
9
ROBINS‐1 risk of bias for patient reported outcome measures
10
10
ROBINS‐1 risk of bias for cosmetic evaluation
11
11
Funnel plot of comparison: 1 Any O‐BCS versus breast‐conserving surgery, outcome: 1.3 Local recurrence: O‐BCS versus S‐BCS.
12
12
Funnel plot of comparison: 1 Any O‐BCSversus breast‐conserving surgery, outcome: 1.7 Overall survival: O‐BCS versus S‐BCS.
13
13
Funnel plot of comparison: 1 Any O‐BCS versus breast‐conserving surgery, outcome: 1.8 Re‐excision rates: O‐BCS versus S‐BCS.
14
14
Funnel plot of comparison: 1 Any O‐BCS versus breast‐conserving surgery, outcome: 1.9 Complications: O‐BCS versus S‐BCS.
15
15
Harvest plot for vote counting: O‐BCS versus S‐BCS ‐ PROMs (Breast‐Q). Each column represents the number of studies that significantly favoured either O‐BCS, S‐BCS or found no significant difference for each Breast‐Q component.
16
16
Harvest plot for vote counting: O‐BCS versus S‐BCS ‐ cosmetic evaluation. Each column represents the number of studies that significantly favoured either O‐BCS, S‐BCS or found no significant difference for BCCT.core scores or panel assessment.
1.1
1.1. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 1: Local recurrence‐free survival (time to recurrence)
1.2
1.2. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 2: Local recurrence
1.3
1.3. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 3: Disease‐free survival (HR)
1.4
1.4. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 4: Disease‐free survival (RR)
1.5
1.5. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 5: Overall survival (HR)
1.6
1.6. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 6: Overall survival (RR)
1.7
1.7. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 7: Re‐excision rates
1.8
1.8. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 8: Complications
1.9
1.9. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 9: Recall rates
1.10
1.10. Analysis
Comparison 1: Any O‐BCS versus S‐BCS, Outcome 10: Time to therapy
2.1
2.1. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 1: Local recurrence (HR)
2.2
2.2. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 2: Local recurrence (RR)
2.3
2.3. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 3: Disease‐free survival
2.4
2.4. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 4: Overall survival (HR)
2.5
2.5. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 5: Overall survival (RR)
2.6
2.6. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 6: Complications
2.7
2.7. Analysis
Comparison 2: Any O‐BCS versus mastectomy (Mx), Outcome 7: Time to therapy
3.1
3.1. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 1: Local recurrence‐free survival
3.2
3.2. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 2: Local recurrence
3.3
3.3. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 3: Disease‐free survival (HR): Mx+R
3.4
3.4. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 4: Disease‐free survival (RR): Mx+R
3.5
3.5. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 5: Overall survival (HR): Mx+R
3.6
3.6. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 6: Overall survival (RR): Mx+R
3.7
3.7. Analysis
Comparison 3: Any O‐BCS versus mastectomy plus reconstruction (Mx+R), Outcome 7: Complications: Mx+R only
4.1
4.1. Analysis
Comparison 4: Volume displacement versus S‐BCS, Outcome 1: Local recurrence
4.2
4.2. Analysis
Comparison 4: Volume displacement versus S‐BCS, Outcome 2: Overall survival
4.3
4.3. Analysis
Comparison 4: Volume displacement versus S‐BCS, Outcome 3: Re‐excision rates
4.4
4.4. Analysis
Comparison 4: Volume displacement versus S‐BCS, Outcome 4: Complications
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Nakada 2019 {published data only}
    1. Nakada H, Inoue M, Furuya K, Watanabe H, Ikegame K, Nakayama Y, et al. Fat necrosis after breast-conserving oncoplastic surgery. Breast Cancer 2019;26(1):125-30. - PubMed
Nakagomi 2019 {published data only}
    1. Nakagomi H, Inoue M, Nakada H, Ohmori M, Nakayama Y, Furuya K, et al. Lateral thoracoaxillar dermal-fat flap for breast conserving surgery: the changes of the indication and long-term results. Breast Cancer 2019;26(5):595-601. - PubMed
Niinikoski 2019 (2) {published data only}
    1. Niinikoski L, Leidenius MH, Vaara P, Voynov A, Heikkila P, Mattson J, et al. Resection margins and local recurrences in breast cancer: Comparison between conventional and oncoplastic breast conserving surgery. European Journal of Surgical Oncology 2019;45(6):976-82. - PubMed
Ojala 2017 {published data only}
    1. Ojala K, Meretoja TJ, Leidenius MH. Aesthetic and functional outcome after breast conserving surgery - comparison between conventional and oncoplastic resection. European Journal of Surgical Oncology 2017;43(4):658-64. - PubMed
Ozmen 2016 {published data only}
    1. Ozmen V, Sarsenov D, Ozmen T, Ilgun S, Alco G, Ordu C, et al. Mini latissimus dorsi flap increases breast conserving surgery rate in early breast cancer patients. Cancer Research 2016;76(4 Suppl):Abstract P2-12-17.
Ozmen 2020 {published data only}
    1. Ozmen V, Ilgun S, Celet Ozden B, Ozturk A, Aktepe F, Agacayak F, et al. Comparison of breast cancer patients who underwent partial mastectomy (PM) with mini latissimus dorsi flap (MLDF) and subcutaneous mastectomy with implant (M + I) regarding quality of life (QOL), cosmetic outcome and survival rates. World Journal of Surgical Oncology 2020;18(1):87. - PMC - PubMed
Palsodittlir 2018 {published data only}
    1. Palsdottir EP, Lund SHL, Asgeirsson KSA. Oncoplastic breast-conserving surgery in Iceland: a population-based study. Scandinavian Journal of Surgery 2018;107(3):224-9. - PubMed
Peled 2014 {published data only}
    1. Peled AW, Sbitany H, Foster RD, Esserman LJ. Oncoplastic mammoplasty as a strategy for reducing reconstructive complications associated with postmastectomy radiation therapy. Breast Journal 2014;20(3):302-7. - PubMed
Piper 2016 {published data only}
    1. Piper M, Peled AW, Sbitany H, Foster RD, Esserman LJ, Price ER. Comparison of mammographic findings following oncoplastic mammoplasty and lumpectomy without reconstruction. Annals of Surgical Oncology 2016;23(1):65-71. - PubMed
PlaFarnos 2018 {published data only}
    1. Pla Farnos MJ, Fernandez-Montoli ME, Garay Garcia L, Garcia Tejedor MA, Campos Delgado M, Verdaguer Menendez-Arango P, et al. Clinical and pathological variables associated to an oncoplastic procedure in breast cancer surgery. European Journal of Cancer 2018;92(Suppl 3):S68.
Potter 2020 {published data only}
    1. Potter S, Trickey A, Rattay T, O'Connell RL, Dave R, Baker E, et al. Therapeutic mammaplasty is a safe and effective alternative to mastectomy with or without immediate breast reconstruction. British Journal of Surgery 2020;107(7):832-44. - PubMed
Ren 2014 {published data only}
    1. Ren ZJ, Li XJ, Xu XY, Xia L, Tang JH. Oncoplastic breast conserving surgery with nipple-areolar preservation for centrally located breast cancer: a retrospective cohort study. Asian Pacific Journal of Cancer Prevention 2014;15(12):4847-9. - PubMed
Rose 2019 {published data only}
    1. Rose M, Svensson H, Handler J, Hoyer U, Ringberg A, Manjer J. Oncoplastic breast surgery compared to conventional breast-conserving surgery with regard to oncologic outcome. Clinical Breast Cancer 2019;19(6):423-432 e5. - PubMed
Rose 2020 {published data only}
    1. 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 Research and Treatment 2020;180(1):247-56. - PMC - PubMed
Santos 2015 {published data only}
    1. Santos G, Urban C, Edelweiss MI, Zucca-Matthes G, Oliveira VM, Arana GH, et al. Long-term comparison of aesthetical outcomes after oncoplastic surgery and lumpectomy in breast cancer patients. Annals of Surgical Oncology 2015;22(8):2500-8. - PubMed
Scheter 2019 {published data only}
    1. Shechter S, Friedman O, Inbal A, Arad E, Menes T, Barsuk D, et al. Oncoplastic partial breast reconstruction improves patient satisfaction and aesthetic outcome for central breast tumours. ANZ Journal of Surgery 2019;89(5):536-40. - PubMed
Sherwell‐Cabello 2006 {published data only}
    1. Sherwell-Cabello S, Maffuz-Aziz A, Villegas-Carlos F, Dominguez-Reyes C, Labastida-Almendaro S, Rodriguez-Cuevas S. Feasibility and cosmetic outcome of oncoplastic surgery in breast cancer treatment. Cirugia y Cirujanos 2015;83(3):199-205. - PubMed
Tang 2016 {published data only}
    1. Tang W, Liu J, Yang H, Jiang Y, Wei W. Clinical comparative study of oncoplastic and standard breast-conserving surgery in the treatment of early breast cancer. Chinese Journal of Clinical Oncology 2016;43:235-9.
Tenofsky 2014 {published data only}
    1. Tenofsky PL, Dowell P, Topaloversuski T, Helmer SD. Surgical, oncologic, and cosmetic differences between oncoplastic and nononcoplastic breast conserving surgery in breast cancer patients. Americal Journal of Surgery 2014;207(3):398-402; discussion 402. - PubMed
Tong 2016 {published data only}
    1. Tong WM, Baumann DP, Villa MT, Mittendorf EA, Liu J, Robb GL, et al. Obese women experience fewer complications after oncoplastic breast repair following partial mastectomy than after immediate total breast reconstruction. Plastic and Reconstructive Surgery 2016;137(3):777-91. - PubMed
Viega 2010 {published data only}
    1. Veiga DF, Veiga-Filho J, Ribeiro LM, Archangelo I Jr, Balbino PF, Caetano LV, et al. Quality-of-life and self-esteem outcomes after oncoplastic breast-conserving surgery. Plastic and Reconstructive Surgery 2010;125(3):811-7. - PubMed
Viega 2011 {published data only}
    1. Veiga DF, Veiga-Filho J, Ribeiro LM, Archangelo-Junior I, Mendes DA, Andrade VO, et al. Evaluations of aesthetic outcomes of oncoplastic surgery by surgeons of different gender and specialty: a prospective controlled study. Breast 2011;20(5):407-12. - PubMed
Vieira 2016 {published data only}
    1. Vieira RA, Carrara GF, Scapulatempo Neto C, Morini MA, Brentani MM, Folgueira MA. The role of oncoplastic breast conserving treatment for locally advanced breast tumors. A matching case-control study. Annals Of Medicine & Surgery (London) 2016;10:61-8. - PMC - PubMed
Wijgman 2017 {published data only}
    1. Wijgman DJ, Ten Wolde B, Groesen NR, Keemers-Gels ME, den Wildenberg FJ, Strobbe LJ. Short-term safety of oncoplastic breast conserving surgery for larger tumors. European Journal of Surgical Oncology 2017;43(4):665-71. - PubMed
Wong 2017 {published data only}
    1. Wong JM, Piper ML, Ewing C, Alvarado M, Esserman LJ, Sbitany H, et al. The use of oncoplastic surgical techniques to increase successful breast conservation in invasive lobular carcinoma of the breast. Cancer Research 2018;78(Suppl 4):Abstract P2-12-16.
Zhou 2019 {published data only}
    1. Zhou L, Wang Y, Cai R, Huang J, Li X, Xie Z, et al. Pedicled descending branch latissimus dorsi mini-flap in repairing partial mastectomy defect: Shoulder functional and esthetic outcomes. Journal of Surgical Oncology 2019;120(3):518-26. - PubMed

References to studies excluded from this review

Adimulam 2014 {published data only}
    1. Adimulam G, Challa VR, Dhar A, Chumber S, Seenu V, Srivastava A. Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: a prospective cohort study. Indian Journal of Cancer 2014;51(1):58-62. - PubMed
Angarita 2019 {published data only}
    1. Angarita F, Elmi M, Cordeiro E, McCready D, Cil T. Oncoplastic surgery is not associated with increased complications when compared to standard breast-conserving surgery: An analysis of the NSQIP Database. Annals of Surgical Oncology 2019;26(2 Suppl):119-20.
Ayoub 2019 {published data only}
    1. Ayoub F, Latifi L, Trapszo P, Seetharam S. Comparison of re-excision rates between standard wide local excision and therapeutic mammoplasty in a district general hospital. European Journal of Surgical Oncology 2019;45(2):E104.
Bogusevicius 2014 {published data only}
    1. Bogusevicius A, Cepuliene D, Sepetauskiene E. The integrated evaluation of the results of oncoplastic surgery for locally advanced breast cancer. Breast Journal 2014;20(1):53-60. - PubMed
Chapa 2019 {published data only}
    1. Chapa L, Chadha M, Jacobs J, Zaretsky E, Boolbol S. Breast-conserving surgery with partial breast reconstruction or reduction mammoplasty followed by whole breast radiation therapy (WBRT). Annals of Surgical Oncology 2019;26(2 Suppl):124.
Cil 2016 {published data only}
    1. Cil TD, Cordeiro E. Complications of oncoplastic breast surgery involving soft tissue transfer versus breast-conserving surgery: an analysis of the NSQIP Database. Annals of Surgical Oncology 2016;23(10):3266-71. - PubMed
Emiroglu 2016 {published data only}
    1. Emiroglu M, Sert I, Karaali C, Aksoy SO, Ugurlu L, Aydin C. The effectiveness of simultaneous oncoplastic breast surgery in patients with locally advanced breast cancer. Breast Cancer 2016;23(3):463-70. - PubMed
Flanagan 2019 {published data only}
    1. Flanagan MR, Zabor EC, Romanoff A, Fuzesi S, Stempel M, Mehrara BJ, et al. A comparison of patient-reported outcomes after breast-conserving surgery and mastectomy with implant breast reconstruction. Annals of Surgical Oncology 2019;26(10):3133-40. - PMC - PubMed
Freitas 2019 {published data only}
    1. Freitas NM, Watanabe PD, Simionatto TF, Yagi NA, Campedelli AF, Martins E, et al. Oncoplastic surgery and the influence of the surgical clip on breast, heart and lung volumes of patients submitted to boost during the planning of breast cancer radiotherapy after lumpectomy. Cancer Research 2020;80(4 Suppl):Abstract P4-12-31.
Fung 2001 {published data only}
    1. Fung KW, Lau Y, Fielding R, Or A, Yip AW. The impact of mastectomy, breast-conserving treatment and immediate breast reconstruction on the quality of life of Chinese women. ANZ Journal of Surgery 2001;71(4):202-6. - PubMed
Geluk 2020 {published data only}
    1. Geluk C, Duijnhoven F, Hoornweg M. Direct or delayed oncoplastic reconstruction after wide local excision for breast cancer in breast conserving therapy: a single centre cohort study of 252 cases. European Journal of Cancer 2020;46(2):e46-7.
Hamilton 2019 {published data only}
    1. Hamilton SN, Nichol A, Wai E, Gondara L, Velasquez Garcia HA, Speers C, et al. Local relapse after breast-conserving therapy versus mastectomy for extensive pure ductal carcinoma in situ >=4 cm. International Journal of Radiation Oncology, Biology and Physics 2019;103(2):381-8. - PubMed
Han 2010 {published data only}
    1. Han J, Grothuesmann D, Neises M, Hille U, Hillemanns P. Quality of life and satisfaction after breast cancer operation. Archives of Gynecology and Obstetrics 2010;282(1):75-82. - PubMed
Hashem 2017 {published data only}
    1. Hashem T, Farahat A. Batwing versus Wise pattern mammoplasty for upper pole breast tumours: a detailed comparison of cosmetic outcome. World Journal of Surgical Oncology 2017;15(1):Article no. 60. - PMC - PubMed
IRCT20111207008316N4 {published data only}
    1. Mehdi Asadi. Evaluation of therapeutic results and patients' satisfaction of oncoplastic techniques in surgery of breast cancer. Iranian Registry Clinical Trials 2018.
Jonczyk 2019 {published data only}
    1. Jonczyk M, Jean J, Graham R, Chatterjee A. New era of modern breast cancer surgery: An 11-year analysis of surgical trends with adoption of breast reconstruction: NSQIP database 2005-2016 analysis. Annals of Surgical Oncology 2019;26(Suppl 1):S69-70 (Abstract no. P8).
Kabir 2015 {published data only}
    1. Kabir SA, Mansell J, Romics L. P086. High incomplete excision rate is strongly associated with lobular subtype, node positivity and tumour size, but independent of hormonal and HER-2 status. In: European Journal of Surgical Oncology. PS51 edition. Vol. 41. 2015:6.
Kabir 2015a {published data only}
    1. Kabir SA, Weiler-Mithoff E, Mansell J, Stallard S, Doughty J, Romics L. P085. Indication for breast conservation for lobular cancer may be extended when oncoplastic techniques used. European Journal of Surgical Oncology 2015;41(6):S50-1.
Kaur 2005 {published data only}
    1. Kaur N, Petit JY, Rietjens M, Maffini F, Luini A, Gatti G, et al. Comparative study of surgical margins in oncoplastic surgery and quadrantectomy in breast cancer. Annals of Surgical Oncology 2005;12(7):539-45. - PubMed
Kawanaka 2019 {published data only}
    1. Kawanaka T, Kubo A, Tonoiso C, Takahashi A, Furutani S, Ikushima H, et al. Use of local boost radiation therapy after breast-conserving surgery with volume replacement oncoplastic method. International Journal of Radiation Oncology 2019;105(1 Suppl):E43.
Kelemen 2016 {published data only}
    1. Kelemen P, Pukancsik D, Ujhelyi M, Kovacs E, Udvarhelyi N, Kenessey I, et al. 72. Comparing oncoplastic breast surgery with conventional breast conserving therapies. Oncological, cosmetic and quality of life outcomes of 350 cases. European Journal of Surgical Oncology 2016;42(9):PS95.
Khan 2018 {published data only}
    1. Khan S, Epstein M, Savalia N, Silverstein M. Extreme oncoplasty: Breast conservation for patients who traditionally require mastectomy. Breast Journal 2018;25(2 Suppl 1):131-2. - PMC - PubMed
Lima 2012 {published data only}
    1. Lima FR, Veiga Filho J, Ribeiro LM, Morais TB, Rocha LR, Juliano Y, et al. Oncoplastic approach in the conservative treatment of breast cancer: analysis of costs. Acta Cirúrgica Brasileira 2012;27(5):311-4. - PubMed
Mondani 2019 {published data only}
    1. Mondani J, Ansari A, Gaber A, Ali Z, Kaushik M. Oncoplastic and reconstructive surgery is a valid option for the treatment of elderly breast cancer patients. British Journal of Surgery - ASIT Poster Presentations 2019;106(Suppl 6):21-169 (Abstract no. 0691).
Moustafa 2016 {published data only}
    1. Moustafa A. Volume displacement techniques for filling partial mastectomy defects. European Journal of Surgical Oncology 2016;42(9):PS121.
Nano 2005 {published data only}
    1. Nano MT, Gill PG, Kollias J, Bochner MA, Carter N, Winefield HR. Qualitative assessment of breast reconstruction in a specialist breast unit. ANZ Journal of Surgery 2005;75(6):445-53. - PubMed
NCT00870415 {published data only}
    1. NCT00870415. Breast-conserving surgery techniques in treating women with breast cancer. clinicaltrials.gov/ct2/show/NCT00870415 (first received 27 March 2009).
NCT02376413 {published data only}
    1. NCT02376413. Oncoplastic breast-conserving surgery in non-metastatic breast cancer patients. clinicaltrials.gov/ct2/show/NCT02376413 (first received 3 March 2015).
NCT03273348 {published data only}
    1. NCT03273348. Role of oncoplastic breast surgery in breast cancer treatment. clinicaltrials.gov/ct2/show/NCT03273348 (first received 6 September 2017).
NCT03900299 {published data only}
    1. NCT03900299. Evaluating new surgical technique in management of female patients with operable multifocal breast cancer. clinicaltrials.gov/ct2/show/NCT03900299 (first received 3 April 2019).
NCT04349527 {published data only}
    1. NCT04349527. Comparison of the cosmetic results, quality of life and patient satisfaction achieved with round-block and retroglandular oncoplastic breast conserving surgeries. clinicaltrials.gov/ct2/show/NCT04349527 (first received 16 April 2020).
Niinikoski 2019 (1) {published data only}
    1. Niinikoski L, Leidenius M, Vaara P, Voynov A, Heikkila P, Meretoja T. Reoperations due to inadequate surgical margins and risk of local recurrence in breast cancer: comparison between conventional and oncoplastic breast conserving surgery. European Journal of Surgical Oncology 2019;45(2):e22-e23. - PubMed
Nisiri 2018 {published data only}
    1. Nisiri A, Pour RO, Zadeh HM, Ramim T. Comparison of surgical margin after breast cancer surgery between oncoplastic technique and conventional breast-conserving surgery. International Journal of Cancer Management 2018;11(4):e9696.
Pearce 2020 {published data only}
    1. Pearce BC, Fiddes RN, Paramanathan N, Chand N, Laws SA, Rainsbury RM. Extreme oncoplastic conservation is a safe new alternative to mastectomy. European Journal of Surgical Oncology 2020;46(1):71-6. - PubMed
Pukancsik 2017 {published data only}
    1. Pukancsik D, Kelemen P, Ujhelyi M, Kovacs E, Udvarhelyi N, Meszaros N, et al. Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: An aesthetic and functional prospective cohort study. European Journal of Surgical Oncology 2017;43(2):303-10. - PubMed
Pukancsik 2019 {published data only}
    1. Pukancsik D, Kelemen P, Ujhelyi M, Kovacs E, Meszaros N, Kasler M, et al. Objective decision making between conventional and oncoplastic breast-conserving surgery or mastectomy: an aesthetic and functional prospective cohort study. European Journal of Surgical Oncology 2019;45(2):e109. - PubMed
Rietjens 2007 {published data only}
    1. Rietjens M, Urban CA, Rey PC, Mazzarol G, Maisonneuve P, Garusi C, et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast 2007;16(4):387-95. - PubMed
Romics 2017 {published data only}
    1. Romics L, Macaskill J, Fernandez T, Morrow E, Simpson L, Pitsinis V, et al. Oncoplastic breast conservations - the Scottish audit: surgical techniques, oncological outcomes, complication rates and variations in practice across the country based on the analysis of 589 patients. Cancer Research 2018;78(4 Suppl):Abstract P4-13-01.
Sun 2014 {published data only}
    1. Sun Y, Kim SW, Heo CY, Kim D, Hwang Y, Yom CK, et al. Comparison of quality of life based on surgical technique in patients with breast cancer. Japanese Journal of Clinical Oncology 2014;44(1):22-7. - PubMed
Tang 2013 {published data only}
    1. Tang JH, Yao YF, Qin JW, Xu XM, Li L. Clinical observation of the immediate breast reconstruction following breast-conserving surgery for centrally located breast cancer. Zhonghua Zhong Liu Za Zhi [Chinese Journal of Oncology] 2013;35(7):518-20. - PubMed
van Paridon 2017 {published data only}
    1. Paridon MW, Kamali P, Paul MA, Wu W, Ibrahim AM, Kansal KJ, et al. Oncoplastic breast surgery: achieving oncological and aesthetic outcomes. Journal of Surgical Oncology 2017;116(2):195-202. - PubMed
Youssef 2017 {published data only}
    1. Youssef M, Namour A, Youssef O, Ahmed M. Oncoplastic breast surgery is oncologically safe in locally advanced breast cancer after neoadjuvant chemotherapy, an Egyptian experience. Indian Journal of Surgical Oncology 2017;72(Suppl 1):S30-1. - PMC - PubMed
Youssef 2018 {published data only}
    1. Youssef MM, Namour A, Youssef OZ, Morsi A. Oncologic and cosmetic outcomes of oncoplastic breast surgery in locally advanced breast cancer after neoadjuvant chemotherapy, experience from a developing country. Indian Journal of Surgical Oncology 2018;9(3):300-6. - PMC - PubMed
Zucca 2012 {published data only}
    1. Zucca Matthes AG, Uemura G, Kerr L, Matthes AC, Michelli RA, Folgueira MA, et al. Feasibility of oncoplastic techniques in the surgical management of locally advanced breast cancer. International Journal of Surgery 2012;10(9):500-5. - PubMed

References to studies awaiting assessment

Srivastava 2018 {published data only}
    1. Srivastava A. BR 23 Score and aesthetic outcome in ladies with early breast cancer undergoing oncoplasty versus conventional breast conservation surgery. European Journal of Cancer 2018;92(Suppl 3):S83-4.

References to ongoing studies

ACTRN12612000638831 {published data only}
    1. ACTRN12612000638831. Effect of breast oncoplastic reshaping on the long term cosmetic outcome after breast conservation surgery: a prospective randomised trial. anzctr.org.au/Trial/Registration/TrialReview.aspx?id=362438 (first received 26 April 2012).
Catsman 2018 {published data only}
    1. Catsman CJ, Beek MA, Voogd AC, Mulder PG, Luiten EJ. The COSMAM TRIAL a prospective cohort study of quality of life and cosmetic outcome in patients undergoing breast conserving surgery. BMC Cancer 2018;18(1):456. - PMC - PubMed
NCT01396993 {published data only}
    1. NCT01396993. Prospective non-randomized evaluation of oncoloplastic surgery (iTOP). clinicaltrials.gov/ct2/show/NCT01396993 (first received 19 July 2011).
NCT02159274 {published data only}
    1. NCT02159274. Shoulder disability and late symptoms following oncoplastic breast surgery. clinicaltrials.gov/ct2/show/NCT02159274 (first received 9 June 2014).
NCT02901223 {published data only}
    1. NCT02901223. The impact of oncoplastic breast surgery on the oncological safety and patient satisfaction. clinicaltrials.gov/ct2/show/NCT02901223 (first received 15 September 2016).
NCT02923635 {published data only}
    1. NCT02923635. A prospective comparative study between oncoplastic breast surgery and standard wide local excision. clinicaltrials.gov/ct2/show/NCT02923635 (first received 4 October 2016).
NCT03012152 {published data only}
    1. NCT03012152. A comparative study between oncoplastic breast surgery and standard conservative surgery: margin status and patient satisfaction. clinicaltrials.gov/ct2/show/NCT03012152 (first received 6 January 2017).
NCT04030845 {published data only}
    1. NCT04030845. Patient report outcome-reconstruction and oncoplastic cohort (PRO-ROC). clinicaltrials.gov/ct2/show/NCT04030845 (first received 24 July 2019).
NTR6901 {published data only}
    1. NTR6901. Patient satisfaction after oncoplastic breast surgery. www.trialregister.nl/trial/6667 (first received 13 December 2017).

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