Cirurgia Oncoplástica Internacional - Europa/Portugal

Algarve Portugal - Oncoplastic Surgery Symposium - Dr. Alexandre Mendonça Munhoz

VILAMOURA/ALGARVE PORTUGAL

HOTEL TIVOLI MARINA

CONGRESSO PORTUGUÊS DE SENOLOGIA 2009

Cirurgia Oncoplástica Internacional

Evento europeu discute aspectos atuais da reconstrução mamária pós câncer de mama

No Algarve/Portugal diversos especialistas na área de câncer de mama discutiram os últimos avanços da especialidade de Mastologia.

A América Latina foi representada pelo cirurgião plástico brasileiro Dr.Alexandre Mendonça Munhoz que proferiu duas palestras sobre a realidade da oncoplástica no Brasil e a segurança oncológica das técnicas de reconstrução.

Oncoplastic Surgery Symposium - Dr. Alexandre Mendonça Munhoz

Entre os renomados professores presentes no evento, merece destaque a participação do grupo da Inglaterra representados pelo Drs.Richard Rainsbury do Royal College of Surgeons e Douglas McMilliam de Nottingham/Inglaterra.

O evento teve a participação de mais de 500 congressistas e iniciou uma nova etapa no intercâmbio de informações Europa-América Latina sobre a cirurgia oncoplástica, suas aplicações no contexto do tratamento moderno do câncer de mama e a realidade presente em cada país e região. Discussões, reflexões e conclusões sobre o evento serão publicadas na revista europeia The Breast. Abaixo segue uma prévia de alguns aspectos discutidos na mesa redonda com os especialistas presentes:

Symposium on Training in Oncoplastic Surgery at the 7th Portuguese Senology Congress

Simpósio Internacional Oncoplástica - Drs. Dick Rainsbury, Douglas McMillam, Maria João Cardoso, Alexandre Mendonça Munhoz e Belén Merck. Dr. Alexandre Mendonça Munhoz - Cirurgia Oncoplástica - Reconstrução Mamária - Reconstrução da Mama - Oncoplastic Surgery - Breast Reconstruction

Introduction

Oncoplastic breast surgery (OPBS) is a major new development in the surgical management of breast cancer. These procedures combine the best principles of tumour resection to achieve wide tumour free margins, with the best principles of reconstruction to avoid major deformity and minimise complications. This type of surgery requires the simultaneous deployment of oncological and reconstructive skills in one operation. OPBS can be performed by the breast surgeon and the plastic surgeon working together (the ‘two team’ approach), or by one team of surgeons with oncoplastic skills. The speed at which new surgical techniques and advances are introduced varies greatly between different countries, depending on different models of specialisation and service delivery. The purpose of this Symposium was to compare and contrast international developments in oncoplastic training and oncoplastic services, with a view to arriving at an international consensus about the key issues which need to be addressed in order to ensure the safe introduction of OPBS into clinical practice. Presenters from Portugal, Spain, Brazil and the United Kingdom were invited to describe their own oncoplastic services, focusing on (a) the history of breast specialisation (b) the current availability of OPBS (c) plans for training in the future. Prior to these presentations, participants used an audience voting system to answer 7 questions, covering 4 key topics related to OPBS
(i) How many breast surgeons are offering OPBS techniques?
(ii) Who should provide this service?
(iii) How well are patients informed, and should these techniques by more freely available?
(iv) How should oncoplastic surgeons be trained?

Following the presentations, these questions were repeated and the results of the ‘before and after’ voting by participants are summarised in Table 1. Provision of oncoplastic services in different countries:

Portugal (Dr Maria João Cardoso)OPBS became available in Portugal some 20 years ago, with the use of expander-based breast reconstruction after mastectomy in 1990, skin-sparing mastectomy in 2000, and breast-conserving reconstruction using volume displacement and replacement in 2005. The availability of OPBS is increasing, because about 60% of breast cancer patients are treated in larger hospitals by in-house teams of breast and plastic surgeons, who are motivated to work together. About 1 in 10 patients undergoing mastectomy have immediate breast reconstruction, and 80% of reconstructions are performed with implants or expanders, in spite of their high cost in Portugal. Approximately 1 in 20 patients undergo breast-conserving reconstruction using a therapeutic mammoplasty or volume replacement technique. The high breast cancer workload restricts the theatre time available for one-stage OPBS, and reimbursement is structured in a way which encourages a two-stage approach because of the greater financial incentive to carry out delayed reconstruction. The reorganisation of specialty training coupled with the national reconfiguration of breast services will increase the availability of OPBS in Portugal in the future. Plans include a breast-specific curriculum and a specialty examination, which will be open to trainees from a background of breast and plastic surgery, as well as from gynaecology. There are also plans to develop a Training Interface Group between breast and plastic surgeons, which will oversee further developments, including the recognition and accreditation of training centres according to their level of activity and expertise.

Spain (Dr Belén Merck)Breast surgery in Spain has traditionally been carried out by general surgeons or gynaecologists, working in breast units in medium to large hospitals. Only a few surgeons were performing OPBS before 2000, when breast surgery was held in low regard. Attitudes changed with the publication of new EUSOMA Guidelines defining standards of training for members of the MDT,1 and with the introduction of postgraduate programmes in Senology and Mastology. This increased the status of breast surgery, as well as the availability of breast units performing and teaching OPBS. Today, most Spanish breast units are run by general surgeons, 40% of whom have had postgraduate training in Mastology. Just over half of these surgeons spend most or all of their time treating breast disease, and 70% work on specialised breast units. Every region now has as dedicated breast unit offering breast reconstruction, most commonly using implants and less frequently using flaps or breast-conserving oncoplastic techniques.A range of intensive training courses have been developed, teaching theoretical and practical skills. In the future a more structured approach needs to be established which offers opportunities for workplace training in reconstruction, and which integrates OPBS into a Spanish curriculum for an emerging new specialty of breast surgery.

Brazil (Dr Alexandre Mendonça Munhoz)
Brazil has an enviable history of innovation and excellence in plastic surgery. The more recent developments in OPBS have taken place in large breast units, where this type of surgery is carried out by teams of breast and plastic surgeons working together. Today, there are approximately 4600 plastic surgeons working in Brazil, leading to a relatively high ratio of 1 plastic surgeon per 40,000 population. About 75% of OPBS is performed by plastic surgeons, and the remainder by general or gynaecological surgeons. Most of these surgeons have trained as ‘Mastologists’. 

The availability of skills in OPBS is reflected in the relatively high (25%) reconstruction rate following mastectomy in patients treated in larger centres.There is an escalating demand for more structured training in OPBS from surgeons with postgraduate training in Mastology who wish to develop these skills. A number of Oncoplastic Fellowships are now available to meet the continued demand which is predicted in the future.

United Kingdom (Mr Dick Rainsbury)

The introduction of a UK National Breast Screening Programme in 1989 was a key factor leading to much greater specialisation in breast surgery. Over the next decade, breast surgery was concentrated in the hands of specialist breast surgeons who lost their general surgical skills. The broad range of technical challenges previously enjoyed by general surgeons was lost, and breast surgery became an increasingly unpopular career option, leading to a ‘recruitment crisis’.2 In response to this crisis, an Interface Training Group was established between breast and plastic surgeons. This initiative was backed up by significant government funding, and resulted in the development of 9 centrally-funded Oncoplastic Fellowship posts, which were launched in 2002. These posts allow Fellows to spend 12 months attached to one of 9 large specialist oncoplastic breast units. These units are in major hospitals around the country, and the posts provide excellent exposure to a full range of OPBS. Each unit is supported by a team of breast and plastic surgeons, a full multidisciplinary team, and an active programme of research and audit. Altogether, 62 Fellowships have been awarded to 49 trainees from general surgery and to13 from plastic surgery. By 2009, 46 Fellows were appointed as consultants and these surgeons are now teaching OPBS to the next generation of trainees. A centrally-funded study of mastectomy and breast reconstruction services in England is currently the subject of a National Mastectomy and Breast Reconstruction Audit, which is assessing access to breast reconstruction services, and measuring clinical and patient-reported outcomes after surgery. Although the Second Annual Report has shown a wide variation in reconstruction rates across the country, there has been an overall increase in immediate breast reconstruction from 10-20% in the last 3 years. This data is now in the public domain3 and will be used to inform patients about the availability and outcomes of this type of OPBS in different hospitals.In the future, OPBS will become more widely available in the UK as the result of 3 key developments.

Algarve Portugal - Dr. Alexandre Mendonça Munhoz - Cirurgia Oncoplástica