Annelotte van Bommel

53 The indicator breast-contour-preserving procedure for primary breast cancer. 4,7–11 Population-based BCS rates have remained stable in recent years in Brazil 7 and the Netherlands, 4 while an increase was observed in some other European countries. 11 Over a similar time period, a decrease in the proportion of patients undergoing BCS was seen in the USA (from 66.6% in 1998 to 61.9% in 2011). 8,12–15 Other studies have reported significant institutional and regional differences in BCS rates, ranging from 20 to 84%. 11,16–20 Increased use of mastectomy combined with IBR over time, differences in IBR rates between countries, 4,7,8,21–24 as well as more frequent application of NAC have also been reported. 4,5,25–28 The observed rise in the rate of BCPP in relation to the observed stable primary BCS rate demonstrates that the composite endpoint has additional value as a local esthetic outcome parameter. This is illustrated in the present study, since a stable rate of primary BCS masks a 22% proportional decrease of patients who underwent a plainmastectomy. The BCPP ratewas similar formost age groups, but the strategies used to maintain the breast contour varied largely between the different age groups. Primary BCS was increasingly used when patients were older, and a concomitant decrease was observed for the proportions of patients who underwent BCS after NAC and those who underwent mastectomy with IBR. In the very young age group, IBR accounted for half of the patients in whom the breast contour was preserved. The difference in the proportion of patients who had primary BCS in relation to the overall proportion undergoing BCPP (17% and 73%, respectively) was most profound in these very young patients (<30 years old). This is in part explained by previous guidelines advising against BCS in the young because of the higher risk of local recurrence and diagnosed genetic mutations. 29 In patients aged >70 years, the low rate of BCPP merely reflected the rate of BCS, since BCS after NAC and mastectomy with IBR were infrequently used (1% and 1%, respectively). The absence of evidence in support of adjuvant chemotherapy in patients older than 70 years explains why NAC was hardly ever administered. The low rate of mastectomy with IBR seems conceivable too, although the extent to which patient preferences explain the observed higher mastectomy rate remains unanswered. BCPP as such was of little additional value in these elderly patients. 3