In the context of surgical de-escalation strategies for breast cancer, including high-risk subtypes, there is an increasing possibility for certain patients to undergo breast conservation using oncoplastic breast-conserving surgical techniques. These include volume replacement, whereby autologous tissue from outside the breast is used to reconstruct the defect following excision, and volume displacement, whereby breast tissue itself is used for reconstruction.¹ As a result of these techniques, many individuals can now undergo breast conservation when previously they were deemed unsuitable due to disease factors such as multifocal disease or a large tumor-to-breast ratio. With increasing training and expertise in oncoplastic surgery, there has been an increase in oncoplastic breast conservation globally. One center in the UK reported an increase from 10.5% to 22.9% from 2016–2023 in a cohort of 3638 breast cancer patients.²

Oncoplastic breast conservation has been shown to confer oncologic safety compared to traditional breast conservation surgery as well as mastectomy with or without reconstruction.^3-5 This aligns with data favoring breast conservation over mastectomy.^6,7 There are also multiple clinical benefits, including fewer postoperative complications and revision surgeries,⁸ as well as a lower rate of wound complications including infection and dehiscence⁹ and reports of less postoperative chest pain and preserved breast sensation following oncoplastic breast conservation.^8,10

In addition, the impact on patients is profound, with potential benefits relating to satisfaction, body image, well-being, and quality of life. Multiple studies show significant improvement in patient-reported outcomes compared to traditional breast conservation surgery, particularly regarding satisfaction with breasts and psychosocial well-being.^11,12 This is supported by a recent meta-analysis of 55 studies and 11 186 breast cancer patients demonstrating improved breast satisfaction (72.0% vs 62.9%, P = 0.02) and psychosocial well-being (78.9% vs 73.3%, P = 0.0001) compared to standard breast conservation surgery.¹³ Other studies have shown no difference in long-term breast satisfaction, sexual well-being and psychosocial well-being over 5 years.¹⁴ In regard to the patient-centered benefits of oncoplastic breast conservation surgery compared to mastectomy with reconstruction, a recent retrospective cohort study of 405 patients found that oncoplastic breast conservation conferred increased breast satisfaction, psychosocial, and sexual well-being.¹⁵ Another recent retrospective study showed significantly improved sexual well-being following oncoplastic breast conservation and a non-significant trend towards improved breast satisfaction and psychosocial well-being.¹⁶

Given the increasing options for oncoplastic breast conservation as well as potential patient-centered benefits, we conducted a systematic review to compare oncoplastic breast conservation surgery and mastectomy with reconstruction in regard to their impact on patient-reported breast satisfaction and quality of life relating to physical, psychosocial, and sexual well-being. This aimed to inform clinical decision-making for patients not suitable for standard breast conservation. To our knowledge, this is the first systematic review comparing patient-reported outcomes of oncoplastic breast conservation surgery (O-BCS) versus mastectomy with reconstruction (M-R) across multiple validated tools.

Out of the 3434 citations identified by our search, a total of 11 studies were deemed suitable for inclusion in the systematic review. Three studies were excluded on the basis that the mastectomy cohort did not undergo reconstruction.^20-22 Two studies were excluded on the basis of not reporting outcomes for the mastectomy and reconstruction cohort.^23,24 One study was excluded on the basis of stratifying patients into young and old cohorts to compare patient-reported outcome measures.²⁵ See Figure 1 for the PRISMA flow chart outlining the selection of studies.

Of the 11 studies included, 6 were prospective and 5 were retrospective cohort studies. All were recently published, between 2017 and 2024, with patient data being collected from 1991 to 2022. There were a total of 1808 patients in the oncoplastic breast conservation surgery cohort and 1413 patients in the mastectomy with reconstruction cohort. All studies except two^26,27 used the validated BREAST-Q questionnaire to assess patient-reported outcomes. Other outcome assessment tools were also used in some studies, including the Body Image Scale (BIS),^27,28 EORTC QLQ-C30 and QLQ-BR23^26,29, Harvard-Harris scale¹⁵, BCCT.core software tool¹⁵ and the 15-D assessment tool.²⁶ See Table 1 for a summary of the study characteristics.

Using the NOS assessment, risk of bias was assessed as moderate (represented by a score of 7 or 8) for 10 studies (7 studies with scores of 8 and 3 studies with scores of 7) and high for one study with a score of 6. See Table 2 for a summary of appraisal according to the NOS.

While most studies showed higher scores for O-BCS in satisfaction and psychosocial well-being, results for physical well-being were mixed, with some favoring M-R. Of the six studies reporting raw unadjusted median BREAST-Q scores, scores were higher for the oncoplastic breast conservation group compared to the mastectomy and reconstruction group regarding psychosocial well-being and tended to be higher for breast satisfaction and sexual well-being, with the exception of Mason et al.¹⁶ and Foley et al.³¹, respectively. Median BREAST-Q scores tended to be lower regarding physical well-being in the oncoplastic group, with the exception of Koppiker et al.³² See Table 3 for a summary of the raw, unadjusted median BREAST-Q satisfaction and well-being scores.

Of the nine studies that compared satisfaction with breasts, five studies^{15,29,31–33} showed improved breast satisfaction in the oncoplastic breast conservation group, and four^10,16,28,30 showed no difference compared to mastectomy and reconstruction.

Of the eight studies reporting on psychosocial well-being, one¹⁵ showed superiority after oncoplastic breast conservation, and seven^{10,16,28–32} showed no significant difference. Regarding sexual well-being, two studies^15,16 showed that oncoplastic breast conservation conferred improved sexual well-being, five^28–32 showed no difference, and one study²⁹ reported improved sexual functioning in the oncoplastic group. Of the seven studies reporting on physical well-being, two^15,30 favored mastectomy and reconstruction, four^16,28,29,32 showed no difference¹⁰, and one¹⁰ favored oncoplastic breast conservation. Further, of the three studies comparing body image, two^27,29 favored oncoplastic breast conservation, and one²⁸ showed no difference. See Table 4 for a summary of the main findings of the included studies.

This systematic review highlights multiple patient-reported benefits regarding satisfaction and well-being for those undergoing oncoplastic breast conservation compared to those undergoing mastectomy and reconstruction, supporting its use as a valid surgical treatment approach for breast cancer patients. The trend favoring improved breast satisfaction is in line with multiple studies demonstrating improvements for those undergoing conventional breast conservation compared to mastectomy, including after implant-based reconstruction.^34,35

The non-inferiority of psychosocial well-being is also consistent with published data regarding breast conservation versus mastectomy.^34,35 In addition, the trend towards improved sexual well-being in our review also supports published findings favoring traditional breast conservation and radiation over mastectomy with or without reconstruction³⁶ and has been shown to strongly correlate with breast satisfaction.³⁷ These results highlight the potentially profound psychological benefits of preserving overall breast integrity for an individual confronted with breast cancer.

The trend towards worse physical well-being for the oncoplastic breast conservation group is highlighted in Davies et al., whereby both therapeutic mammaplasty and chest wall perforator subgroups had significantly worse physical well-being scores at 3 and 12 months, both compared to their respective baselines and to the mastectomy and mastectomy with immediate reconstruction cohorts.³⁰

This has also been demonstrated after conventional breast conservation and may reflect radiation-related chest wall discomfort, which disproportionately affects O-BCS patients undergoing adjuvant therapy.¹³ It is interesting that the psychosocial benefit has been shown to prevail despite the adverse impact on chest symptoms and physical well-being.

This systematic review highlights the utility of oncoplastic breast conservation in the modern era of increasing neoadjuvant systemic therapy use for high-risk subtypes of breast cancer, with uses including the assessment of tumor biology, treatment of occult metastatic disease, and downstaging of large tumors to render breast conservation possible.

Two studies in this systematic review evaluated clinical and patient-reported outcomes following neoadjuvant chemotherapy for breast cancer. Koppiker et al. showed a 72.8% rate of conversion from planned mastectomy to oncoplastic breast conservation, with significantly higher satisfaction with breasts and outcome in the oncoplastic group compared to the mastectomy and immediate reconstruction group.³²

Di Leone showed better physical well-being and equivalent breast satisfaction and psychosocial well-being, but no difference in disease-free or overall survival between the oncoplastic and mastectomy with reconstruction groups.¹⁰ The oncologic safety of oncoplastic breast conservation for high-risk subtypes is highlighted by a SEER analysis of 24 621 triple-negative and HER2-positive breast cancer patients showing improved 5-year breast cancer-specific survival in those undergoing oncoplastic breast conservation with radiation compared to standard breast conservation or mastectomy with radiation.³⁸

Both in the setting of upfront surgery and neoadjuvant systemic therapy, our systematic review has important therapeutic implications. In addition to the oncologic safety and clinical benefits of oncoplastic breast conservation compared to mastectomy and reconstruction, the overall improved patient-reported outcomes support the validity of oncoplastic breast conservation as an alternative to mastectomy and reconstruction. This enhances the notion that oncoplastic breast conservation should be offered as a valid option where it is indicated and feasible as part of a patient-centered, individualized treatment approach. This may also confer more global benefits regarding healthcare expenditure, with lower costs of care for those undergoing oncoplastic surgery with adjuvant radiation compared to mastectomy and reconstruction.³⁹

To our knowledge, this is the first systematic review to compare patient-reported outcomes regarding satisfaction and well-being in multiple domains between breast cancer patients undergoing oncoplastic breast conservation and mastectomy with reconstruction. This is clinically relevant with the ability to guide patient-centered decision-making and a collaborative and multidisciplinary treatment approach for those diagnosed with breast cancer. This is particularly important in the modern context of breast surgery, where advances in volume replacement and displacement oncoplastic techniques allow many patients to undergo breast conservation with an aesthetically favorable reconstruction when they would have previously been deemed unsuitable. This is also important in the setting of increasing indications for breast conservation, particularly with the more widespread use of neoadjuvant systemic therapy. Our study also benefited from a comprehensive publication search of multiple databases by 2 investigators. Although comprehensive, the use of Google Scholar may introduce bias due to the inclusion of non-peer-reviewed sources.

Despite these strengths, this study has several limitations. Inherent to the nature of qualitative patient-reported data, there is subjectivity in the results, which is compounded by multiple sources of heterogeneity both within and between the included studies. The majority of studies did not adjust for preoperative baseline scores, for which there may be considerable variation between individuals. Only Gulis et al. adjusted for psychiatric comorbidities of the patients, and the lack of adjustment in all other studies may have significantly influenced the outcomes, given the potentially strong impact of pre-morbid psychological state on well-being and satisfaction, particularly in the setting of a derailing breast cancer diagnosis.

Further, there were differing time courses for patient-reported outcome assessments between the studies, from 6 months to 12 months and longer, with a potential impact on contemporaneous well-being scores, especially if the patients were undergoing adjuvant chemotherapy. The different types of reconstruction also add to the heterogeneity of results. The mastectomy cohort in most studies comprised both implant-based and autologous reconstruction, while Chand et al. compared oncoplastic breast conservation to latissimus dorsi mini-flaps.³³ This heterogeneity is reflected in the moderate to high risk of bias of each study as appraised by the NOS (Table 2).

In addition, the presentation of data in multiple ways resulted in an inability to reliably collate the results as a meta-analysis, limiting their significance and applicability. This systematic review was also subject to selection bias of patients, with a significant rate of loss to follow-up in several of the included studies.^15,31 This may reflect the attrition of patients, both highly satisfied with their outcome and not wanting to attend further surgical follow-up as well as those dissatisfied with their outcome and seeking a second opinion.¹⁵ Further, this study was subject to publication bias as a systematic review of published studies rather than original data.

To strengthen the validity and applicability of our results, future research should incorporate longitudinal BREAST-Q tracking across multiple time points. This would evaluate the impact of oncoplastic breast conservation and mastectomy with reconstruction over the long term to evaluate the continuing effect of patient-related outcomes over time. When patient volume allows, future studies should perform subgroup analyses between different oncoplastic breast conservation techniques and different post-mastectomy reconstruction techniques to determine the most favorable patient-centered surgical options. In addition, the impact of satisfaction and well-being should be evaluated following neoadjuvant systemic therapy, not just after conventional chemotherapy and targeted HER2 treatment, but also following neoadjuvant immunotherapy, including PD-1 inhibitors for high-risk early triple-negative breast cancer.⁴⁰

Our systematic review highlights the positive impact of oncoplastic breast conservation compared to mastectomy and reconstruction, especially in regard to potentially improved breast satisfaction, psychosocial, and sexual well-being. This shows that, where indicated and feasible, oncoplastic breast-conserving surgery should be offered as a valid surgical alternative to mastectomy and reconstruction as part of a patient-centered individualized treatment approach for breast cancer. These findings can inform shared decision-making and personalized surgical planning, particularly in borderline or high-risk cases.

Ethical approval was not required for this study.