Indian Surgeons’ Perspective Regarding Breast-Conserving Surgery: A Cohort Study

INTRODUCTION

Breast-conserving surgery (BCS) is a legacy of Umberto Veronesi who laid the groundwork for preservation of the body image of women affected by breast cancer with the Milan I study in the late 1970s. Treatment of breast cancer has evolved with the advancement in the screening technique, development of alternative surgical approach and radiation technologies, and coordination of multidisciplinary team to implement multifaceted treatment.

BCS has the advantage of less invasive surgery, shorter recovery time, and better psychological outcomes (satisfaction with body image and social acceptance) than MRM. In a randomized controlled trial, BCS + radiation therapy (RT) has been shown to be at least equivalent or even superior to mastectomy.^[1,2] When BCS + RT was compared to mastectomy alone, 3-, 5-, and 10-year survival was 96.5% vs. 93.4%, 92.9% vs. 88.35% and 80.9% vs. 67.2% respectively.^[3] Despite of all these facts and results, both Indian surgeons and patients have been slow to adopt this treatment method, and mastectomy rates are still higher for a variety of reasons.

Breast surgery is a territory that is catered by general surgeons and multiple other subspecialists (oncosurgeons, breast surgeons) in India. It is seen that general surgeons usually prefer mastectomy for early breast cancer (EBC), whereas BCS is preferred and mostly performed by trained breast surgeons. These variations are observed depending on the training and intent to treat. The main reason leading to low rates of BCS is the lack of surgical skills required for BCS and breast reconstruction. Some surgeons still have the impression that mastectomy is clinically superior to BCS because of low risk of recurrence. Only 10% of patients with EBC in India undergo BCS^[4] compared to 70% in the USA.^[5] Thus, it is imperative that surgeons know the practice of other surgeons in their own country and also abroad. The available technologies make the surgery safer for the surgeon and patient, so the learning and unlearning exercise is necessary in the field of surgery. We aimed to study the Indian surgeon’s perspective on BCS.

MATERIALS AND METHODS

We developed a questionnaire with 20 questions regarding various aspects of BCS. The link to the questionnaire (Questionnaire No. 1) was sent by emails to general surgeons, oncosurgeons, endocrine and breast surgeons, and breast specialists throughout India. They filled in the questionnaire by logging into a dedicated website, www.sgpgibreast.in. The emails were sent to members of the associations of breast surgeons, endocrine surgeons, and surgeons in India.

Social media in the form of Facebook and WhatsApp was also used to send this request to different surgeon groups. The filled in questionnaire was available and sent through mail to the corresponding author. The question was entered in an Excel sheet and then converted into a Statistical Package for Social Sciences (SPSS) sheet and analyzed. The consent was given in the website, and once consent is provided by the surgeons, the questionnaire is then filled in. The response of the surgeons was kept confidential. This study was approved by the ethics committee of the institution.

STATISTICAL ANALYSIS

In the descriptive statistics, continuous variables were presented as mean ±SD, while categorical variables were presented as frequency (%). To test the association between various questions asked from the surgeons and age, educational standard, fellowship status, clinical experience in years, clinical setup, number of patients per year, and sex, Pearson’s chi-square test or Fisher’s exact test was used as appropriate. A P-value <0.05 was considered statistically significant. SPSS version 23 (IBM, Chicago, USA) was used in the statistical data analysis.

RESULTS

A total of 1200 emails were sent to surgeons practicing breast surgery in India. A total of 112 (9.3%) surgeons responded to the request, of which 40 were breast and endocrine surgeons or breast specialists, 40 were oncosurgeons performing breast surgery, and 32 were general surgeons performing breast surgery.

When the age of the surgeon was taken into consideration in analyzing the responses, we found that surgeons in the 20–30-year age group performed MRM more than BCS (P = 0.017), believed that BCS is not equivalent to MRM in terms of disease outcome (P = 0.012), did not mark the cavity with metallic clip (0.009), and were keen on attending the training for BCS [Table 1]. When comparing a surgeon with superspecialty degree and a surgeon with specialty degree, we found that majority of superspecialists performed BCS (P < 0.01), provided long-term disease control (P < 0.01), routinely marked the cavity (P < 0.001), and provided self- administered systemic therapy (P = 0.006), while special surgeons liked to attend BCS training (P = 0.014) [Table 2]. When comparing surgeons with and without dedicated breast fellowship, surgeons with fellowship (93.8%) performed oncoplastic procedures (P < 0.001) and marked the cavity with clip (P = 0.001), while surgeons without fellowship liked to attend BCS training (P = 0.003) [Table 3]. When surgeons were compared according to their clinical experience (0–5, 5–10 and >10 years), we found that surgeons with <5 years’ experience and >10 years’ experience performed BCS less (P < 0.001) and liked to attend BCS training (P = 0.002) [Table 4].

When surgeons were analyzed according to the clinical setup, which is governmental, private, or both, we found that private surgeons routinely sent the margins for frozen section biopsy (0.010), and surgeons working in governmental setup were keen on attending BCS training (P = 0.001) [Table 5]. When surgeons were analyzed based on number of cases operated per year (0–20, 20–10, and >100), surgeons with more than >100 cases routinely performed BCS (P < 0.001), practiced SLNB, used both blue dye and radiopharmaceutical agent, routinely performed oncoplastic procedures (P < 0.001), and routinely marked the cavity [Table 6]. When male and female surgeons were compared, there was no significant difference [Table 7].

DISCUSSION

The response by email and use of social media lead to only 9.3% of surgeons filling the questionnaire. Some studies have a 38%^[6] response rate, whereas others have up to 80%^[7] in a developing country where there are several responsibilities for young surgeons, including counseling, surgical work, and postoperative care. Even because of several chemotherapy administrations and numerous mails^[8] requesting such research and association activities, this kind of poor response is observed. We did not send multiple reminders to avoid disturbance to academic surgeons who have to multitask different aspects of life.

Young (20–30 years) and old surgeons (>50 years) performed more MRM. This is probably due to lack of training in the case of old surgeons where they were exposed to radical mastectomy and in the case of young surgeons the fear of recurrence and tarnishing of image in case of failure in initial cases, which can have disastrous results in their career. In a study by Monica Morrow, the concern about excessive use of MRM by surgeons was addressed, and they found that patient’s preference, contraindication to BCS, or adjuvant therapy were the primary reasons.^[9]

In our study, sex was not significant. However, in one study, female surgeons spent more time with the patients and were successful in convincing patients to undergo BCS.^[10] The outlook for BCS by male/female surgeons did not change in this study. Superspecialty surgeons trained in elite institutions, since only very few superspecialty seats are available throughout India, were comfortable in performing BCS with SLNB. General surgeons with less exposure to BCS training have to be trained to save breasts.

Surgeons with >100 breast cases per year were comfortable in BCS, and this is expected as patients in this modern era approach surgeons with excellent results. One study found that patients treated in smaller hospitals by older surgeons frequently undergo MRM.^[11] Compared with institutions of excellence and reputed institutions, governmental institutions have lesser high-technology equipment, including frozen section facility, compared to private setup. This kind of logistics issues can impede BCS in a developing country.

The intent to learn and unlearn in surgeons for the sake of improved quality of treatment and life for the patient is the most important factor in performing BCS in an eligible patient. The setup, qualification, technology, patient preference, sex of the surgeon, and clinical setup also play a role.

CONCLUSION

We conclude that robust training of surgeons in the BCS of breast cancer saves breast as well as quality of life.