General introduction

Background

One in eight women (12.5%) developed breast cancer in the Netherlands in 2012. The introduction of the national breast cancer screening program and new insights into multidisciplinary oncologic treatment of breast cancer have resulted in earlier detection, improved treatment and a reduction in mortality (Otto, 2012).

 

In addition to optimal oncologic care, the cosmetic end-result is also important to patients, leading to reassessment of both breast conserving treatment and mastectomy. Discussing the possibility of immediate breast reconstruction following mastectomy, or delayed breast reconstruction at a later stage are now considered a standard part of preoperative information given to women. In addition, tissue rearrangement procedures (oncoplastic surgery), designed to improve the cosmetic result of breast conserving surgery are becoming increasingly common.

 

Identification of genetic mutations (including BRCA1 and BRCA2) and the associated increased risk of developing breast cancer has resulted in an increased demand for prophylactic bilateral mastectomy in often very young women (Lostumbo et al 2010; Arver et al 2011; Metcalfe et al 2012). This has contributed to the increased demand for (immediate) breast reconstructions.

 

Innovations in the field of reconstructive microsurgery and training of more microsurgeons have made complex, labor-intensive microsurgical reconstructions, in which skin and/or fat tissue is transplanted (particularly Deep Inferior Epigastric Argery Perforator (DIEP) flap procedures), available to more patients.

 

Finally, increased patient empowerment and greater availability of information about different breast reconstruction options has resulted in an increased demand for various types of breast reconstruction.

 

All of the above has resulted in greater demands being placed on plastic surgeons to participate in the multidisciplinary care for patients with breast cancer or an increased risk of breast cancer. Due to increasing numbers and more time-intensive procedures, plastic surgeons and other members of the multidisciplinary cancer team not only face logistic challenges, but also new questions that have yet to be addressed by existing guidelines.

 

The need for a guideline

The treatment of breast cancer is complex and multidisciplinary by nature, with treatment protocols that are updated continually. This guideline can help order and summarize scientific evidence, based on which multidisciplinary breast cancer teams can make substantiated choices about issues including timing and type of breast reconstruction in combination with oncological treatments. Additionally, the guideline can help share knowledge about breast reconstruction with other (non-plastic surgery) team members, thus improving communication between various team members. The guideline can also contribute to optimizing the delivery of care and support for breast reconstruction patients. Ultimately, this may improve the overall quality of life of breast reconstruction patients.

 

The field of breast reconstruction is continuously evolving. Innovation is important because it can lead to better care. The guideline summarizes the scientific evidence for safety, added value and efficacy of the most important innovations in breast reconstruction, and formulates recommendations regarding the use of these novel techniques in daily practice.

 

The ongoing increase in healthcare costs is a cause for concern and may ultimately affect breast reconstruction care. Expensive, complex microsurgical procedures are becoming increasingly common. Therefore, the guideline also contains a chapter on the costs of various breast reconstruction techniques.