Breast Surgery Outcome Measures Group

The long-term success of breast cancer surgery is measured primarily by local control. However, in an era when breast cancer patients are more likely to survive their disease (78% 10-year survival, Cancer Research UK) and local recurrence rates are minimal, the physical and psychological effects of treatment, especially long-term effects, are even more relevant.

Studies have shown that psychological and social recovery from breast-conserving therapy (surgery and radiotherapy for breast cancer) is better if the appearance after surgery is better, yet there is no widely accepted way to evaluate appearance. Patient-reported outcome is subjective and influenced by psychological status before the diagnosis, and expectations of treatment and panel assessments of appearance (using clinicians and/or lay people) are expensive and time-consuming.

3D-Surface Imaging (3D-SI) gives clinicians the ability to review images in three dimensions, to view the breasts as the patient views them (in the mirror or looking down) and paves the way for a new understanding of post-operative appearance. The software associated with 3D-SI can provide accurate and reproducible length, volume and symmetry measurements. We believe that this novel technology may be harnessed to provide a new and cost-effective objective evaluation of post-treatment aesthetic outcome. This would be a useful tool in quality improvement and audit, but would also serve as a robust end point in surgical trials.

Present studies

Validation of 3D surface imaging – breast model and patient pilot studies

Our initial studies were of the accuracy and precision of 3D surface imaging. We checked accuracy and precision using a plasticine model of the breast and ensured that two observers’ results were comparable. Next, we imaged a small number of ladies who had previously had breast cancer surgery to assess reproducibility and repeatability and to ask for their feedback on the acceptability of the process.

Measuring the outcome of breast conserving surgery

Two hundred and fifty patients have kindly undergone 3D surface imaging, standard 2D photography, and completed a patient-reported outcome questionnaire, the BREAST-Q. We have published our results from the patient-reported outcome questionnaire and are now assessing the concordance between patients’ own assessment of their appearance, the panel’s assessment of 2D photographs and 3D surface images, and objective measurements taken from the 3D images. We are investigating whether there are any factors associated with a poor cosmetic outcome, other than those previously noted such as the size of the tumour as a percentage of breast volume.

Measuring the impact of treatment sequencing

Radiotherapy has the potential for a detrimental impact on all forms of breast reconstruction. Women are often advised not to undergo immediate breast reconstruction after mastectomy if it is anticipated that radiotherapy will be required (as shown in the National Mastectomy and Breast Reconstruction Audit). The literature is divided about the impact of radiotherapy on autologous breast reconstruction using DIEP flaps (tummy skin and fat), but the studies were small and evaluations not objective. We have imaged a cohort of 170 women who have previously had DIEP flap surgery, either before, after, or without radiotherapy and are studying the impact of radiotherapy on their appearance, satisfaction and quality of life.

We are also carrying out 3D surface imaging of women participating in the PRADA study, a novel study of irradiating the breast before mastectomy and DIEP flap reconstruction, to provide a secondary endpoint of appearance.

Future studies

Objective outcome measure

In order to replace the assessment of images by a panel of clinicians, we need to know which of the measurements available contribute most to the experts’ scoring. We intend to measure various aspects of the image and use statistical techniques to predict the panel’s score. We will then test the scoring system in a further group of patients.

Simulation of post-operative appearance using 3D-SI

While surgery and radiotherapy develop in pursuit of the perfect appearance post-treatment, better management of patient expectation may enable more appropriate decision-making by the doctor-patient partnership (e.g. mastectomy and recon rather than an attempt at breast conservation). The use of 3D surface imaging to simulate patients’ likely outcome may result in better preparation and satisfaction with the outcome than is possible by explanations or by showing 2D photos of other patients. This would have widespread applicability in the NHS and beyond.

External funding

Royal College of Surgeons of England one-year research fellowship (Rachel O’Connell)

The Royal Marsden and ICR's NIHR Biomedical Research Centre two-year research fellowship (Amy Godden).