Thirty-six panellists — radiation oncologists, breast surgeons, a plastic surgeon and medical physicists — worked through 97 items over two Delphi rounds on the local management of a second ipsilateral breast cancer event, with consensus set at 75% agreement and endorsement from US and European surgical and radiation oncology societies. Agreement was reached on 78 items.
The central one is unanimous: a second breast-conserving therapy is a reasonable option for selected patients, and patient preference is central to the decision. The features the panel associated with suitability were an interval of at least 60 months between the two operations, a low-risk accelerated partial breast irradiation classification, a luminal molecular profile, and no grade 3 late toxicity from the first course of breast-conserving therapy. Tumour-to-breast volume ratio, clear margins and tumour bed reirradiation all reached strong consensus as considerations. Notably, HER2-positive and triple-negative subtypes were not treated as absolute contraindications. Where mastectomy is chosen, immediate autologous reconstruction was preferred by 94% over implant-based reconstruction at 75%.
This changes a conversation that has often not been held. Salvage mastectomy has been the default for a recurrence or new primary in a previously irradiated breast, and many patients were never offered an alternative. The consensus provides the criteria to identify who can reasonably be offered conservation again, and reirradiation of the tumour bed is the technical requirement that makes it feasible. Treat it for what it is — expert consensus, not trial evidence — and use it to structure the discussion, with the patient's own preference given the weight the panel gave it.
- Offer repeat breast-conserving therapy as an option where the interval since the first surgery is 60 months or more.
- Check for grade 3 late toxicity from the first course before proposing reirradiation.
- Do not exclude a patient on HER2-positive or triple-negative subtype alone.
- Assess tumour-to-breast volume ratio early — it decides feasibility more often than biology does.
- Where mastectomy is chosen, discuss immediate autologous reconstruction first.
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