as a result of prospective randomised controlled trials ( rcts ) beginning in the 1970s , breast conservation therapy ( bct ) was adopted as an appropriate alternative for the treatment of breast cancer and has been an accepted option for more than three decades [ 15 ] . a consensus statement in 1991 endorsed bct as the surgical therapy of choice , for it offered similar survival rates while preserving the form of the breast . recent data suggests that in the presence of modern adjuvant therapies , instead of equivalent survival outcomes , bct could be superior to mastectomy for the treatment of breast cancer [ 610 ] . a large retrospective analysis evaluating women with early breast cancer similar to those in one rct demonstrated a higher 10-year breast - cancer - specific survival for women who had undergone bct when compared with mastectomy with or without radiation [ 2 , 6 ] . for patients who had characteristics unlike those in the rcts , higher mastectomy rates were found to be associated with poorer survival outcomes [ 79 ] , and , in a prospective series studying hormone - positive tumours , bct resulted in lower local recurrence rates and improved survival . despite the longstanding acceptance of bct , its utilisation in predominantly chinese communities has been reported to be lower than in western populations [ 6 , 1118 ] . approximately 7585% of women with early stage breast cancer are expected to be candidates for bct , yet bct rates in predominantly chinese populations are reported to average 30% , even for t1-t2 tumours [ 1115 ] ( table 1 ) . an absolute improvement of 4% in breast - cancer - specific survival rates was reported with bct rates of 70% . it was also estimated that , for each 1-percentage - point rise in the mastectomy rate , there would be a concomitant fall in 7-year survival by 0.1% . it can be inferred from these calculations that , on a population basis , no survival benefit is expected with a mastectomy rate of 70% . there is therefore a pressing need to relook at surgical treatment in predominantly chinese communities as a persistently low bct rate could translate to suboptimal outcomes . the reasons cited for low bct rates include cultural preferences , surgeon bias , and factors relating to physical attributes [ 1115 ] . chinese women have been shown to have smaller breast tissue volume , which poses challenges for good cosmetic outcomes in bct . this study was therefore performed to review the authors ' experience in treating women with bct in a predominantly chinese community , evaluate bct rates in this cohort , and compare it with prior reports . a retrospective analysis of all patients with breast malignancies who underwent operative treatment by clinicians at this medical facility between october 2008 and december 2011 was performed . preoperative diagnostic workup consisted of clinical examination and standard imaging with mammography and sonography , and percutaneous needle biopsies were done for diagnosis where possible . in certain clinical settings where percutaneous biopsy was not possible or inconclusive , like where there was insufficient compression thickness or discordant imaging and biopsy results , following diagnosis , patients deemed eligible for bct were given the option of an attempt at breast conservation or to proceed directly to mastectomy , with or without reconstruction . eligibility for bct was made based on the surgeon 's assessment of the ability to achieve a reasonable cosmetic result after tumour resection with clear margins . multifocal and multicentric breast cancers ( mfmcbc ) were not considered to be ineligible if preoperative evaluation indicated the possibility of en bloc excision of all foci through a single incision . if the tumour(s ) was assessed to be too large , the patient was offered neoadjuvant medical therapy and had placement of radioopaque clip(s ) prior to its commencement . these were localised before wide excision , which was guided by the position(s ) of the marker clip(s ) . patients who were assessed to be eligible for bct and who agreed to undergo a trial of bct had wide excision of their lesion(s ) performed through a single incision . incisions were planned such that they coursed over the lesions where possible . in the instances where there were more than one tumour foci , if the other lesion(s ) were more than 2  cm away from the incision , radioopaque clips were positioned in the tumour bed for ease of radiotherapy administration . following tumour extirpation with negative margins , this was performed by mobilising full thickness parenchymal flaps off the pectoralis fascia , advancing the pillars and directly apposing them with sutures . all patients who were intended for bct had intraoperative frozen section analysis ( ifsa ) for margins status . if margins were positive at the time of surgery , further margins were excised until proven to be negative . successful bct of mfmcbc was defined as operative attainment of clear margins ( no ink on tumour )   and a reasonable cosmetic outcome . in clinical scenarios mastectomy was also performed for patients according to preference for breast removal rather than bct . the patients were referred both to a medical oncologist and to radiation oncologists for discussions relating to the need for further adjuvant treatment . whole breast irradiation was given for women who underwent bct with a boost to the tumour bed according to the preference of the radiation oncologist . patients who underwent mastectomy with large tumours , more than 3 positive axillary lymph nodes , and lymphovascular invasion were treated with postmastectomy radiotherapy . statistical analyses of the respective associations were performed using spss ( chicago , il ) version 11 advanced statistical software module . continuous variables with median or mean values were compared using the student 's t - test or mann - whitney u test where appropriate . however , 6 were lost to follow - up before any cancer - related events were noted , leaving 171 for analysis . fifteen of these ( 62.5% ) had contraindications to bct based on size and improbability of attaining negative margins without compromising cosmesis , while nine elected to have a mastectomy despite being eligible for bct . the mean age of these patients who chose a mastectomy was 58 years , which was significantly higher than that of those who underwent bct , whose mean age was 47.9 years ( p = 0.003 ) . there was no significant difference between the mean ages of patients who had bct and those who underwent mastectomy out of necessity ( mean age : 50.1 years ) based on therapeutic principles ( p = 0.40 ) . the majority of the cohort was chinese ( 66.7% ) and was generally expected to have smaller volume breast tissue than women of other ethnicities [ 15 , 20 ] . there were a fair proportion of caucasian women and women of other ethnic origins as well , and no difference in the proportion of women undergoing bct based on ethnicity was demonstrated ( p = 0.88 ) . one hundred and fifty - six of the total of 171 ( 91.2% ) were assessed to be suitable candidates for bct . however , nine patients of 156 ( 5.8% ) decided against bct . the main reasons given by these few patients were a perceived superiority of survival with mastectomy and reduction of anxiety relating to follow - up . the mean tumour size for patients who underwent bct was 19.2  mm , while that for women who elected for mastectomy despite being suitable candidates for bct was 18.3  mm . in contrast , there was a significant difference in the mean tumour sizes of women who had bct and those who were advised to undergo a mastectomy , the latter group of which had a mean tumour size of 40.5  mm ( p < 0.001 ) . four patients in the cohort ( 2.3% ) required a second therapeutic surgical procedure , three for undetected multicentric tumours seen on postoperative imaging and a fourth for a falsely negative sentinel lymph node ( sln ) at ifsa . the last patient had multifocal disease with two separate foci of invasive ductal carcinoma , grade iii , 35  mm and 8  mm , and 2 of 22 lymph nodes involved . all four patients who needed reoperation had multifocal or multicentric breast cancers ( mfmcbc ) and are currently disease - free . the mean pathologic tumour size for those requiring reoperation was 32.3  mm , while those who had a single operation had a mean tumour size of 20.8  mm ( p = 0.14 ) . there were no patients who required a reexcision on the basis of false negative margins at ifsa . none of the 22 patients who presented with ductal carcinoma in situ only developed locoregional recurrence or distant metastasis . of the other 149 patients with invasive carcinoma , two patients who underwent bct developed local failure ( 1.4% ) . a total of four patients with invasive disease , two who had undergone bct and two mastectomy , developed distant disease and have succumbed to their disease ( 2.3% ) . the last two decades of the twentieth century witnessed a paradigm shift of treatment concepts for breast cancer , with definitive evidence from prospective randomised trials demonstrating that performing less surgery resulted in equivalent survival outcomes . unexpectedly , in the last decade , a rising trend of mastectomy rates has been observed in some western communities [ 16 , 23 ] . despite this rise , mastectomy rates for early breast cancer in these countries are still lower than the high rates reported in predominantly chinese populations . mastectomy rates need to be reexamined in the presence of contemporary reports indicating possible higher cancer - specific survival , lower surgical complication rates , cost - effectiveness of treatment , and improved quality of life outcomes with bct [ 610 , 21 , 2428 ] . this is juxtaposed against the possible psychological benefit that mastectomy and contralateral prophylactic mastectomy ( cpm ) offer [ 24 , 29 ] , but the diminution of anxiety might not completely compensate for poorer quality of life outcomes with longer breast cancer survivorship [ 26 , 30 ] . specifically for predominantly chinese populations , reasons cited for low bct rates include cultural preferences , surgeon bias , and factors relating to physical attributes [ 1115 ] . addressing the issue of physical attributes first , chinese women tend to have smaller volume breast ( svb ) tissue which may pose a barrier to bct [ 15 , 20 ] . in this series , overall bct rate was 85.9% . among chinese women , who formed two - thirds of the cohort , bct rate was 86% . there was no significant difference of the proportion of chinese women undergoing bct compared with women of other ethnic groups . this rate is similar to other reported series in a western context ( table 1 ) . this data appears to suggest that the physical attributes of chinese women may not have a significant impact on bct rates . in a study by collins et al . , of 125 women who were eligible for either bct or mastectomy , 35% elected to have a mastectomy . in the present study , of 156 patients who were considered eligible for bct or mastectomy , only 5.8% decided against breast conservation . this data suggests that the local chinese culture may be a factor in favour of bct , rather than a condition in support of high mastectomy rates . another factor influencing patient decision for mastectomy is surgeon 's advice . in this study , 156 of 171 patients ( 91.2% ) were assessed preoperatively to be suitable candidates for bct . nine patients decided in favour of mastectomy , making utilisation of bct in this cohort 94.2% . eligible patients who decided for mastectomy had a mean tumour size not significantly different from those who underwent successful bct . hence , it is reasonable to conclude that successful bct would have been possible for this group of women , suggesting that , on the whole , eligibility of chinese women for bct is not significantly different from women of other ethnic origins . the difference perhaps is surgeon philosophy , which may account for varying reported mastectomy rates in different geographical locations [ 23 , 33 ] . surgeons with a strong bias toward mastectomy will require clinical circumstances extremely favourable for bct before contemplating it , while surgeons whose default position is conservative surgery would be more inclined to explore innovative methods of achieving bct even in challenging clinical situations . the authors prefer the use of only volume displacement or local tissue rearrangement techniques with direct apposition of adequately mobilised residual uninvolved parenchymal pillars with sutures . this approach results in better patient satisfaction than mastopexy and avoids the issues with surgical clip migration with the use of mammoplasty techniques which require extensive tissue mobilization [ 21 , 34 , 35 ] . moreover , local tissue rearrangement techniques result in lower complication rates and superior cosmetic outcomes compared to complex reconstructive techniques . although the presence of multicentric disease , or mfmcbc , is a conventional contraindication for bct , a recent expert consensus considers this scenario a relative rather than an absolute contraindication . mfmcbc pose technical challenges for bct but may be surmounted with careful attention to surgical planning and technique . patients initially considered ineligible for bct by some surgeons might in fact be suitable candidates once appropriate measures are applied , avoiding based on imaging findings and percutaneous biopsy results , these two patients were recommended to have a mastectomy at another tertiary referral cancer centre . a second opinion was sought with the authors and they were willing to undergo a  trial of bct .  both underwent successful bct and are now disease - free more than five years after surgical treatment . for example , unlike guidelines which recommend skin crease incisions , radial incisions may be necessary to incorporate larger lesions , multiple tumours , and allow adequate exposure for remodelling to avoid deformity [ 38 , 39 ] ( figures 1 and 2 ) . however , recent data suggest that this increase in identification of mfmcbc with mri results in higher mastectomy rates without definitive improvement in survival outcomes [ 40 , 41 ] . hence , a selective approach should be taken with the use of preoperative mri . in this study , because preoperative mri was not used , four patients , all of whom had multiple ipsilateral cancers , required a reoperation . mri may be applied when multiple cancers or extensive microcalcifications are detected on conventional imaging to avoid reoperations . however , further work may be necessary in this area to assess specific selection criteria for its use to balance this need against a potential for increasing mastectomy use in this group of patients . the reported rise in mastectomy rates is observed with a concomitant increase in the use of contralateral prophylactic mastectomy ( cpm ) [ 24 , 25 ] . factors contributing to this phenomenon include the use of preoperative mri , the presence of multicentric disease , the availability of reconstructive surgery , fear of cancer recurrence , concerns over the risk of contralateral breast cancer ( cbc ) , and a perceived survival benefit with mastectomy [ 24 , 29 ] . the first three factors , which may also influence high mastectomy rates in chinese populations , are clinician related and have been discussed earlier . the latter three involve patient psychology and information dissemination for decision - making . data on how communication methods and decision aids affect patient 's surgical decisions is varied [ 3133 , 42 ] . it is interesting to note that bct tends to be preferred in women without breast cancer , but once diagnosed , higher mastectomy rates as the definitive operation were reported with greater patient involvement in decision - making . in the light of recent data that higher mastectomy rates could lead to poorer survival outcomes , a reexamination of patient decision - making processes is needed . one factor which may influence patient choice in favour of mastectomy despite eligibility for bct is the availability of reconstruction . while reconstruction does lead to improved body image , its availability prior to a  trial of bct  may have an adverse effect on bct rates , possibly encouraging not only mastectomy but cpm as well . some authors have concluded that , based on current evidence , the use of cpm for the purposes of risk reduction in sporadic breast cancer is unjustified [ 25 , 44 ] . arriving at the delicate balance between a paternalistic approach recommending treatment associated with evidence - based superior outcomes and allowing patient autonomy in decision - making is complex and elusive . this difficulty can make a  simple can be harder than complex  situation in the pursuit of improvements in bct . further work on this subject is warranted . in a surgical era where there is increasing public acceptance towards less invasive procedures for equivalent outcomes in breast cancer , as has been seen in the paradigm shifts with percutaneous breast biopsies and the management of the axilla , it is perplexing that bct rates are persistently low in predominantly chinese communities , and mastectomy and cpm rates are rising in other populations . recent data showing the potential for improved survival , lower complication rates , cost - effectiveness , and better body image during survivorship with bct [ 610 , 21 , 25 , 26 ] behoves clinicians to consider means of increasing its utilisation . the surgeon factor has been shown to affect bct rates [ 32 , 45 , 46 ] . . it may be reasonable to surmise that surgeons recommending bct apply operative techniques to surmount patient 's physical attributes of svb . careful attention to clinical approaches and surgical technique may raise bct rates in a predominantly chinese community from approximately 30% to 86% , minimising unnecessary mastectomies in this population . further work is needed to investigate if the concepts for improving utilisation of bct in a population with prevailing low bct rates may be applied in other settings to reverse a trend of rising mastectomy rates . in addition , the authors ' practice in a private healthcare facility may serve as a selection bias where women who actively sought bct were treated at the authors ' facility . notwithstanding , the distribution of tumour sizes is not dissimilar from other reports where oncoplastic reduction mammoplasty was performed [ 34 , 35 ] , indicating that the concepts discussed herein may be applicable to other healthcare settings to raise bct rates . higher bct rates demonstrated in this study than previously reported for predominantly chinese communities suggest that it is possible to minimise unnecessary mastectomies in this select population .
background . 
 recent data shows that the use of breast conservation treatment ( bct ) for breast cancer may result in superior outcomes when compared with mastectomy . however , reported rates of bct in predominantly chinese populations are significantly lower than those reported in western countries . 
 low bct rates may now be a concern as they may translate into suboptimal outcomes . 
 a study was undertaken to evaluate bct rates in a cohort of predominantly chinese women . 
 methods . 
 all patients who underwent surgery on the breast at the authors ' healthcare facility between october 2008 and december 2011 were included in the study and outcomes of treatment were evaluated . 
 results . 
 a total of 171 patients were analysed . two - thirds of the patients were of chinese ethnicity . 
 one hundred and fifty - six ( 85.9% ) underwent bct . 
 ninety - eight of 114 chinese women ( 86% ) underwent bct . 
 there was no difference in the proportion of women undergoing bct based on ethnicity . 
 after a median of 49 months of follow - up , three patients ( 1.8% ) had local recurrence and 5 patients ( 2.9% ) suffered distant metastasis . 
 four patients ( 2.3% ) have died from their disease . 
 conclusion . 
 bct rates exceeding 80% in a predominantly chinese population are possible with acceptable local and distant control rates , thereby minimising unnecessary mastectomies .