Thirty-six panellists — radiation oncologists, breast surgeons, a plastic surgeon and medical physicists, endorsed by US and European societies — worked through 97 items on managing a second ipsilateral breast cancer event after primary breast-conserving therapy, with consensus set at 75% agreement. Agreement was reached on 78 items (80%) after two rounds.
Two items reached 100%: that patient preference is central to the decision, and that a second breast-conserving therapy is a reasonable option in selected patients. The features that made a patient more suitable were an interval of at least 60 months between surgeries, a low-risk accelerated partial breast irradiation classification, a luminal molecular profile, and no grade 3 late toxicity from the first treatment. Notably, HER2-positive and triple-negative subtypes were not regarded as absolute contraindications. Tumour-to-breast volume ratio, clear margins and tumour bed reirradiation all drew strong consensus. Where mastectomy is chosen, immediate autologous reconstruction was preferred (94%) over implant-based reconstruction (75%).
The default in most units has been mastectomy for any in-breast recurrence, on the reasoning that the breast has had its radiotherapy. This says the question is worth asking properly, and gives four concrete criteria to ask it with. It remains expert opinion, not trial data — the randomised comparison does not exist — but it is expert opinion from the people who would be doing either operation.
- Record the interval since the first surgery; 60 months is the threshold the panel used
- Check the molecular profile and the late toxicity grade from the first course before defaulting to mastectomy
- Do not exclude second conservation on HER2-positive or triple-negative status alone
- Where mastectomy is chosen, discuss immediate autologous reconstruction first
- Reirradiation capability varies widely between Indian centres; confirm what your radiation oncology service can deliver before offering it
Why it matters
It reopens a decision most units have been making automatically in one direction.
Don't overread it
Delphi consensus is structured expert opinion, not evidence that second conservation matches mastectomy for local control.
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