Liu et al.

BMC Surgery (2022) 22:31

https://doi.org/10.1186/s12893-022-01488-0

RESEARCH Open Access

Breast conserving therapy for central breast

cancer in the United States
Jiameng Liu1,2†, Xiaobin Zheng1,5†, Shunguo Lin2,3,4, Hui Han2,3,4 and Chunsen Xu2,3,4*

Abstract
Introduction: Although central breast cancer is not a contraindication to breast conserving, most surgeons still
choose to perform total mastectomy. The safety of breast conserving treatment for central breast cancer is still
unclear. The purpose of this study is to evaluate the long-term survival outcome of central breast cancer.
Materials and methods: Using SEER database to explore the trend of surgical procedures for patients with central
breast cancer. The patients were divided into breast conserving group and non-breast conserving group. Multivari-
ate logistic regression was used to evaluate predictors of breast conserving surgery in central breast cancer. The
clinicopathological variables were adjusted through the multivariable Cox risk model, and the stage and T stage were
stratified to compare survival results.
Results: A total of 8702 patients with central breast cancer underwent surgical treatment from 2010 to 2015. There
were 3870 patients in the breast conserving group and 4832 patients in the non-breast conserving group. The breast
preservation rate was 44.4%, which rose from 39.9% in 2010 to 51% in 2015. Elderly patients (p < 0.001) and low tumor
malignancy were predictors of breast conserving therapy. In the 1:1 matched case–control analysis, breast cancer-
specific survival (BCSS) (p < 0.001) and overall survival (OS) (p < 0.001) in breast conserving therapy group were still
higher than those of non-breast conserving. In the subgroup analysis of T staging and stage, the breast conserving
therapy group still had higher OS and BCSS.
Conclusion: In central breast cancer, breast-conserving therapy is safe and optional.
Keywords: Central breast cancer, Nipple-areola complex, Breast conserving therapy, Overall survival, Breast cancer-
specific survival

Introduction Central breast cancer usually refers to tumors located

Breast conserving therapy (BCT) allows patients to in the area within 2 cm of the nipple-areola complex
achieve esthetic outcomes, quality of life and preserve (NAC). The research on BCT of central breast can-
their breast without sacrificing oncologic outcome [1– cer were few and small sample size though the results
3] and is considered as a safe treatment for early-stage showed acceptable recurrence rate of BCT in central
breast cancer. breast cancer (4.8–7%) [4–6] and the non-inferior sur-
vival outcomes [5, 7, 8] compared with non-BCT. So for
central cancers breast conserving therapy was not con-
traindication in the guideline, but was less likely to be
*Correspondence: xuchunsen@yeah.net recommended by surgeons for reasons below: (1) care-
†
Jiameng Liu and Xiaobin Zheng have contributed equally to this work ful pathologic examination of mastectomy specimens
and share first authorship
2
Department of Breast Surgery, Fujian Medical University Union Hospital, has found that more than 30% involve the nipple-areola
No. 29, Xinquan Road, Fuzhou 350001, Fujian, China complex [9–11] and lumpectomies that remove the
Full list of author information is available at the end of the article nipple-areola complex often result in poor cosmesis. (2)

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Liu et al. BMC Surgery (2022) 22:31 Page 2 of 11

Perceived increase in the risk of local recurrence owing to Statistical analysis

inadequate margins. Recent stunning result was reported Chi-squared testing was used to compare the differences
from a SEER data based research including 16522 cen- in baseline characteristics between patients treated with
tral breast cancer which showed an improved survival non-BCT versus patients treated with BCT. Multivaria-
rate for centrally located breast cancer (CLBC) receiving ble logistic regression was used to identify factors associ-
BCT [12]. But the early studies on the safety of BCT for ated with surgery type. Kaplan–Meier analysis was used
CLBC [4, 13–16] or the comparation of oncological out- to compare overall survival outcomes between patients
comes between BCT and non-BCT [7, 8] and the recent treated with different surgery type. Univariate and Mul-
SEER based result [12] were all constrained to T1-2 stage tivariate Cox regression analysis was used to assess
without taking T3-4 into account which cannot meet potential factors affecting breast cancer-specific survival
the increasing demand for more cosmetically acceptable (BCSS) and overall survival (OS) in patients with central
breast cancer surgery. Also HER-2 status was an impor- breast cancer. Factors evaluated in the multivariate analy-
tant factors influencing the survival outcome of breast sis model included surgery type, age at diagnosis, race,
cancer, which was not included in the recent SEER based marital status, year at diagnosis, grade, T stage, N stage,
result. So a study on the survival difference between BCT ER status, PR status, and HER-2 status. To diminish the
and non-BCT in central and NAC, especially in T3-4 effects of baseline differences on outcome differences
subgroup population is urgently need. in the BCT and non-BCT groups, the propensity score
matching (PSM) method was applied by matching each
Materials and methods BCT case to non-BCT cases. They were exactly matched
Data source and study population for the age, race, marital status, grade, T stage, N stage,
The Surveillance, Epidemiology, and End Results (SEER) ER status, PR status and HER-2 status. P < 0.05 was con-
database was used to evaluate the safety of breast con- sidered as an indicator of statistical significance. SPSS
serving therapy. We acquired permission to download statistics (version 22, IBM, NY) was used to conduct all
and analyze data for academic purpose (reference num- the above analyses.
ber: 10727-Nov2020). This study does not contain any
experiments on humans as well as animals and/or the Results
use of human tissue samples performed by any of the The trend of BCT and non‑BCT among central breast cancer
authors. The SEER cancer registries provide population- and relevant clinical characteristics
based cancer surveillance for 17 areas that represent From 2010 to 2015, a total of 8702 patients met our inclu-
approximately 26% of the United States. Inclusion cri- sion criteria and were included for analysis. The study
teria: (1) the diagnosing year ranged from 2010 to 2015, consisted of 3870 (44.4%) patients with BCT and 4832
(2) the primary site of tumor was breast, (3) tumor site (55.6%) patients with non-BCT. The clinical characteris-
was central portion of breast (C50.1) or nipple (C50.0), tics of the BCT and non-BCT groups were summarized
and (4) patients underwent breast surgery. Exclusion cri- in Table 1. BCT was performed more frequently since
teria: (1) patients with stage IV disease, (2) patients with 2010. Older patients, white patients, married patients,
unknown information of race, diagnosing year, marital gradeII, early stage, T1 stage, N0 stage, ER positive, PR
status or important clinicopathological data, (3) patients positive, HER-2 negative were more likely to receive BCT,
younger than 18 years old or elder than 80, (4) patients and the proportion of those factors differed significantly
with a history of other cancer, (5) patients with less than between BCT and non-BCT group except for mari-
1 month survival after diagnosis, and (6) patient’s diag- tal status. Comparing patients treated with non-BCT,
noses were only depended on biopsy or autopsy. Finally, patients initially treated with BCT were older at diagno-
a total of 8702 adult breast cancer patients aged 19 to sis (P < 0.001), have lower grade (P < 0.001), lower TNM
79 years between 2010 and 2015 was included, and we stage (P < 0.001), lower T stage (P < 0.001), lower N stage
stratified patients into 2 groups by type of surgery: breast (P < 0.001) and more likely to be ER positive at diagnosis
conserving therapy (n = 3870) and non-breast conserv- (P < 0.001), PR positive at diagnosis (P < 0.001) and HER-2
ing therapy (n = 4832). The non-breast conserving ther- negative at diagnosis (P < 0.001). They are also more likely
apy included mastectomy and breast reconstruction. to be of white race (P < 0.001). Figure 1 showed a trend
Liu et al. BMC Surgery (2022) 22:31 Page 3 of 11

Table 1 Comparison of patient and tumor characteristics

60.1%
between the BCT and non-BCT group 60
58.1% BCT
BCT group Non-BCT group P-value 57.5%
non−BCT

No % No %
55 55.5%

percentage of surgery
53.4%
Years at diagnosis < 0.001
2010 570 14.70 859 17.80 51%
2011 598 15.50 745 15.40 50
2012 627 16.20 868 18.00 49%
2013 619 16.00 836 17.30
2014 681 17.60 779 16.10 46.6%
45 44.5%
2015 775 20.00 745 15.40
Age < 0.001 42.5%
< 45 249 6.40 717 14.80 41.9%
39.9%
40
45–59 1331 34.40 1861 38.50
2010 2011 2012 2013 2014 2015
60–79 2290 59.20 2254 46.60
year of diagnosis
Race < 0.001
White 3165 81.80 3711 76.80 Fig. 1 Proportion of patients with central breast cancer who
underwent BCT and those who underwent non-BCT diagnosed
Black 349 9.00 474 9.80
between 2010 and 2015
Others 356 9.20 647 13.40
Marital 0.439
Married 2370 61.20 2911 60.20
Single 577 14.90 767 15.90 of BCT for T1-4 central breast cancer and the BCT rate
Divorced 923 23.90 1154 23.90 (51%) exceeded non-BCT in 2015.
Grade < 0.001
Grade I 1037 26.80 780 16.10 Predictive factors of BCT among central breast cancer
Grade II 1908 49.30 2343 48.50 The results of multivariate logistic regression are
Grade III 918 23.70 1692 35.00
reported in Table 2. Results confirmed that higher T
Grade IV 7 0.20 17 0.40
stage (P < 0.001; T2: OR 0.447, 95% CI 0.402–0.496; T3:
Stage < 0.001
OR 0.152, 95% CI 0.118–0.195; T4: OR 0.182, 95%CI
Stage I 2218 57.30 1311 27.10
0.134–0.247), higher N stage (P < 0.001; N1: OR 0.634,
Stage II 1439 37.20 2198 45.50
95%CI 0.570–0.706; N2: OR 0.304, 95%CI 0.242–0.381;
Stage III 213 5.50 1323 27.40
N3: OR 0.216, 95%CI 0.150–0.311), positive HER-2 sta-
T stage < 0.001
tus (P = 0.004; OR0.822 95%CI 0.719–0.940) and higher
T1 2766 71.50 1924 39.80
grade (P = 0.014; Grade II: OR 0.843, 95%CI 0.747–0.951;
T2 971 25.10 1961 40.60
Grade III: OR 0.819, 95%CI 0.707–0.949) were inde-
pendently associated with non-BCT. Other significant
T3 79 2.00 598 12.40
predictors of BCT include higher age (45–59 years: OR
T4 54 1.40 349 7.20
2.026, 95% CI 1.706–2.405; 60–79 years: OR 2.581, 95%
N stage < 0.001
CI 2.182–3.053) and years at diagnosis (OR 1.076, 95% CI
N0 2810 72.60 2266 46.90
1.048–1.106).
N1 917 23.70 1687 34.90
N2 107 2.80 560 11.60
N3 36 0.90 319 6.60 Survival significance of BCT among central breast cancer
ER status < 0.001 The Kaplan–Meier survival curve showed that BCT
Negative 434 11.20 742 15.40 group had better OS and BCSS than non-BCT group
Positive 3436 88.80 4090 84.60 (Fig. 2, both P < 0.001). For patients with central breast
PR status < 0.001 cancer, type of surgery, age, race, marital status, years
Negative 800 20.70 1263 26.10 at diagnosis, grade, T stage, N stage, ER status, PR
Positive 3070 79.30 3569 73.90 status and HER-2 status were considered as poten-
HER-2 status < 0.001 tial prognostic variables and were included in the ini-
Negative 3350 86.60 3889 80.50 tial univariate and multivariate models. The results of
Positive 520 13.40 943 19.50 the univariate analysis proportional hazard regression
Liu et al. BMC Surgery (2022) 22:31 Page 4 of 11

Table 2 Multivariate logistic regressions model for predictors of 0.522–0.766; P < 0.001) and breast-specific death hazard
breast conserving therapy (HR 0.570; 95%CT 0.435–0.746; P < 0.001) in the adjust
Factor OR 95%CI P-value multivariate Cox analysis. Other factors including age
(P < 0.001), race (P < 0.001), marital status (P < 0.001),
Age < 0.001 years at diagnosis (P = 0.038), grade (P < 0.001), T stage
< 45 1 Reference (P < 0.001), N stage (P < 0.001), ER status (P = 0.003),
45–59 2.026 1.706–2.405 < 0.001 PR status (P < 0.001) and HER-2 status (P = 0.039)
60–79 2.581 2.182–3.053 < 0.001 were identified as independent significant predictors
Race < 0.001 of T1-4 central breast cancer overall mortality (OM),
White 1 Reference and race (P < 0.001), marital status (P = 0.007), grade
Black 1.030 0.874–1.213 0.725 (P < 0.001), T stage (P < 0.001), N stage (P < 0.001), ER
Others 0.680 0.585–0.79 < 0.001 status (P = 0.005), PR status (P < 0.001) and HER-2 sta-
Marital 0.059 tus (P = 0.008) were identified as independent signifi-
Married 1 Reference cant predictors of central breast cancer breast-specific
Single 1.146 1.001–1.313 0.049 mortality (BCSM).
Divorced 0.952 0.850–1.067 0.4
Year of diagnosis 1.076 1.048–1.106 < 0.001 BCT as a prognostic factor for survival after propensity
Grade 0.014 score matching
Grade I 1 Reference To further corroborate the findings from univariable
Grade II 0.843 0.747–0.951 0.005 and multivariable proportional hazard regression, a pro-
Grade III 0.819 0.707–0.949 0.008 pensity score-adjusted analysis was performed. A total
Grade IV 0.477 0.182–1.251 0.132 of 2757 patients who underwent BCT were matched to
T stage < 0.001 2757 patients who underwent non-BCT. Within the post-
T1 1 Reference propensity cohort, there was no difference between both
T2 0.447 0.402–0.496 < 0.001 groups with regards to age (P = 0.114), race (P = 0.527),
T3 0.152 0.118–0.195 < 0.001 marital status (P = 0.287), grade (P = 0.669), T stage
T4 0.182 0.134–0.247 < 0.001 (P = 0.722), N stage (P = 0.547), ER status (P = 0.579), PR
N stage < 0.001 status (P = 0.409) and HER-2 status (P = 0.458) (Table 5).
N0 1 Reference Using Kaplan–Meier survival estimates, BCT was asso-
N1 0.634 0.57–0.706 < 0.001 ciated with improved OS (P = 0.001) (Fig. 3) in the post-
N2 0.304 0.242–0.381 < 0.001 propensity cohort. In the subgroup analysis based on the
N3 0.216 0.150–0.311 < 0.001 post-propensity cohort. The beneficial impact of BCT on
ER status 0.987 survival was additionally confirmed stratified for stage,
Negative 1 Reference and the P value were 0.018 for stage I, 0.009 for stage
Positive 1.002 0.829–1.209 0.987 II, and 0.004 for stage III (Fig. 4). The BCT group had a
PR status 0.082 higher OS compared with the non-BCT group in T1-2
Negative 1 Reference (P < 0.001) and T3-4 (P = 0.037) (Fig. 5).
Positive 1.141 0.984–1.323 0.082
HER-2 status 0.004
Negative 1 Reference Discussion
Positive 0.822 0.719–0.94 0.004 BCT involves excision of the tumor (lumpectomy) fol-
lowed by adjuvant whole breast irradiation (WBI). In
order to perform BCT, it must be possible to excise the
tumor to negative margins with an acceptable cosmetic
identified BCT significantly reduced overall death outcome, the patient must be able to receive radiother-
hazard (HR 0.396; 95%CT 0.332–0.473; P < 0.001) and apy, and the breast must be suitable for follow-up to
breast-specific death hazard (HR 0.266; 95%CT 0.206– allow prompt detection of local recurrence. Landmark
0.342; P < 0.001) (Tables 3, 4). And BCT still signifi- trials have established that breast conservation therapy
cantly reduced overall death hazard (HR 0.633; 95%CT (BCT) and mastectomy offer equivalent survival and can
Liu et al. BMC Surgery (2022) 22:31 Page 5 of 11

A B
p<0.001 p<0.001

1.0 1.0

BCSS
OS

0.8 0.8
BCT
BCT
non-BCT
non-BCT
0.6 0.6
0 20 40 60 80 100 0 20 40 60 80 100
Months Months
Fig. 2 Kaplan–Meier survival curves of overall survival and breast cancer-specific survival stratified by BCT and non-BCT (A: OS; B: BCSS)

be viewed as equivalent treatments in early stage breast and English (63%) [23]. We found a higher proportion
cancer (ESBC) [17, 18]. Breast conserving therapy fol- of older age, single marital status, later years at diagno-
lowed by radiotherapy allows patients to achieve esthetic sis, lower grade, lower T stage, lower N stage, ER posi-
outcomes, quality of life and preserve their breast with- tive status, PR positive status and HER-2 negative status
out sacrificing oncologic outcome [1–3] and is consid- to receive BCT for CLBC and those factors were thought
ered as a safe treatment for early-stage breast cancer. to be associated with favored outcome.
The term subareolar defined differently: Fowble et al. The young breast cancer always develops more aggres-
[7] and Haffty et al. [6] defined it as the area within 2 cm sive tumors at diagnosis, like hormone receptor nega-
of the NAC, Haagensen shrank the distance to only 1 cm, tive, higher grade, and HER-2 negative [24] and it is not
and Simmons et al. [5] defined it as the area immediately contraindication for BCT for early stage patients. In our
beneath the areola. Central tumors usually refer to sub- logistic analysis, we found that there is a significantly
areolar with some exceptions: only include NAC [19], lower proportion of a young age (< 45 yeasts old) in BCT
tumors > 2 cm from areolar margin [7]. NAC malignant group (6.40%) compared with non-BCT group (14.8%).
tumors included Paget disease, lymphoma and invasive With the popularization of BRCA1/2 genetic testing and
and noninvasive breast cancers [20] and Paget disease the maturity of breast reconstruction surgery, more and
were also a candidate for BCT [21]. In our study NAC more young women are choosing breast reconstruction
account for 6.42% (559/8702) central and NAC patients, and contralateral prophylactic mastectomy [25, 26]. This
and the type of surgery did not correlated with location may be why more young women are not opting for breast
significantly (p = 0.692). But to date, the research on BCT conserving surgery.
of the NAC breast cancer is limited, so NAC breast can- The evidence for breast conserving surgery has
cer were included for further study. The early studies on expanded with the availability of more drugs and
the safety of BCT for CLBC [4, 13–16] or the compa- improved efficacy of neoadjuvant therapy. Breast con-
ration of oncological outcomes between BCT and non- serving surgery is not limited to early stage, such as
BCT [7, 8] and the recent SEER based result [12] were all T1–T2, but can be extended to T3–4. In our research,
constrained to T1–2 stage. So in our study, T3–4 patients the OS rate of central breast cancer patents was higher
were included. Wang’s study compared the safety of BCT with breast conserving surgery than with mastectomy,
versus mastectomy for CLBC [22]. But in our study, non- which was consistent with Zhang’s results [12]. How-
breast conserving patients included not only mastec- ever, our study demonstrates that T3–T4 and stage III
tomy, but also breast reconstruction. patients receiving breast conserving therapy also had
Our result showed a trend of BCT for CLBC and it higher OS (P < 0.05).
exceed non-BCT in 2015, and the proportion of BCT was And BCT significantly reduced overall death haz-
similar to whole breast cancer reported in French (57%) ard (HR 0.633; 95%CT 0.522–0.766; P < 0.001) and
Liu et al. BMC Surgery (2022) 22:31 Page 6 of 11

Table 3 Univariable and multivariable models of overall mortality in central breast cancer patients
Univariate analysis Multivariate analysis
HR (95%CI) P-value HR (95%CI) P-value

Surgery type < 0.001 < 0.001

Non-BCT Reference
BCT 0.396 (0.332–0.473) < 0.001 0.633 (0.522–0.766) < 0.001
Age < 0.001 < 0.001
< 45 Reference Reference
45–59 1.029 (0.769–1.378) 0.846 1.188 (0.885–1.595) 0.252
60–79 1.581 (1.201–2.080) 0.001 2.012 (1.518–2.668) < 0.001
Race < 0.001 < 0.001
White Reference Reference
Black 1.922 (1.568–2.356) < 0.001 1.509 (1.222–1.864) < 0.001
Others 0.630 (0.466–0.851) 0.003 0.566 (0.418–0.767) < 0.001
Marital < 0.001 < 0.001
Married Reference Reference
Single 1.596 (1.301–1.959) < 0.001 1.366 (1.106–1.686) 0.004
Divorced 1.829 (1.544–2.166) < 0.001 1.465 (1.231–1.742) < 0.001
Year of diagnosis 0.929 (0.877–0.984) 0.012 0.941 (0.888–0.997) 0.038
Grade < 0.001 < 0.001
Grade I Reference Reference
Grade II 1.392 (1.081–1.793) 0.01 1.025 (0.792–1.326) 0.85
Grade III 3.189 (2.497–4.071) < 0.001 1.581 (1.211–2.065) 0.001
Grade IV 4.950 (2.004–12.224) 0.001 2.438 (0.977–6.08) 0.056
T stage < 0.001 < 0.001
T1 Reference Reference
T2 2.288 (1.906–2.747) < 0.001 1.48 (1.214–1.805) < 0.001
T3 4.055 (3.208–5.126) < 0.001 1.947 (1.498–2.529) < 0.001
T4 6.933 (5.452–8.817) < 0.001 2.845 (2.169–3.731) < 0.001
N stage < 0.001 < 0.001
N0 Reference Reference
N1 1.83 (1.525–2.195) < 0.001 1.461 (1.205–1.772) < 0.001
N2 3.999 (3.214–4.976) < 0.001 2.482 (1.956–3.149) < 0.001
N3 6.087 (4.802–7.716) < 0.001 3.180 (2.443–4.140) < 0.001
ER status < 0.001 0.003
Negative Reference Reference
Positive 0.362 (0.307–0.427) < 0.001 0.692 (0.544–0.880) 0.003
PR status < 0.001 < 0.001
Negative Reference Reference
Positive 0.407 (0.350–0.475) < 0.001 0.666 (0.536–0.828) < 0.001
HER-2 status 0.004 0.039
Negative Reference Reference
Positive 1.318 (1.094–1.588) 0.004 0.813 (0.668–0.989) 0.039
Liu et al. BMC Surgery (2022) 22:31 Page 7 of 11

Table 4 Univariable and multivariable models of breast cancer-specific mortality in central breast cancer patients
Univariate analysis Multivariate analysis
HR (95%CI) P-value HR (95%CI) P-value

Surgery type < 0.001 < 0.001

Non-BCT Reference Reference
BCT 0.266 (0.206–0.342) < 0.001 0.570 (0.435–0.746) < 0.001
Age < 0.001 0.894
< 45 Reference Reference
45–59 1.131 (0.843–1.518) 0.411 1.075 (0.79–1.463) 0.645
60–79 1.904 (1.437–2.524) < 0.001 1.069 (0.785–1.455) 0.672
Race < 0.001 < 0.001
White Reference Reference
Black 1.505 (1.218–1.859) < 0.001 1.473 (1.137–1.91) 0.003
Others 0.581 (0.429–0.787) < 0.001 0.549 (0.374–0.806) 0.002
Marital < 0.001 0.007
Married Reference Reference
Single 1.355 (1.097–1.672) 0.005 1.244 (0.957–1.618) 0.103
Divorced 1.478 (1.243–1.758) < 0.001 1.43 (1.141–1.792) 0.002
Year of diagnosis 0.935 (0.882–0.99) 0.022 0.949 (0.881–1.022) 0.167
Grade < 0.001 < 0.001
Grade I Reference Reference
Grade II 1.04 (0.804–1.346) 0.763 1.763 (1.109–2.803) 0.017
Grade III 1.612 (1.233–2.106) 0 3.159 (1.984–5.029) < 0.001
Grade IV 2.439 (0.977–6.091) 0.056 4.019 (1.179–13.706) 0.026
T stage < 0.001 < 0.001
T1 Reference Reference
T2 1.616 (1.329–1.966) < 0.001 1.913 (1.441–2.54) < 0.001
T3 2.241 (1.733–2.897) < 0.001 2.798 (1.998–3.919) < 0.001
T4 3.251 (2.487–4.25) < 0.001 4.072 (2.868–5.782) < 0.001
N stage < 0.001 < 0.001
N0 Reference Reference
N1 1.532 (1.264–1.857) < 0.001 1.907 (1.465–2.483) < 0.001
N2 2.725 (2.151–3.452) < 0.001 3.525 (2.599–4.781) < 0.001
N3 3.518 (2.706–4.573) < 0.001 4.546 (3.282–6.297) < 0.001
ER status 0.003 0.005
Negative Reference
Positive 0.695 (0.546–0.885) 0.003 Reference 0.005
PR status < 0.001 < 0.001
Negative Reference Reference
Positive 0.664 (0.534–0.825) < 0.001 0.519 (0.395–0.681) < 0.001
HER-2 status 0.045 0.008
Negative Reference Reference
Positive 0.818 (0.672–0.995) 0.045 0.723 (0.569–0.918) 0.008
Liu et al. BMC Surgery (2022) 22:31 Page 8 of 11

Table 5 Comparisons of clinicopathological characteristics breast-specific death hazard (HR 0.570; 95%CT 0.435–
between the BCT and non-BCT group in 1:1 matched case– 0.746; P < 0.001) in the adjust multivariate Cox analysis.
control analysis When dug deeply, we found that there is a higher pro-
Non-BCT BCT P-value portion of older age, single marital status, more recent
years at diagnosis, lower grade, lower T stage, lower N
No % No %
stage, ER positive status, PR positive status and HER-2
Year of diagnosis < 0.001 negative status to receive BCT for CLBC and those fac-
2010 478 17.30 420 15.20 tors were thought to be associated with favored survival
2011 420 15.20 426 15.50 outcome. To eliminate the effect of those confound-
2012 500 18.10 436 15.80 ers on prognosis analysis, propensity match score was
2013 480 17.40 437 15.90 used. Post-match cohort showed an improved survival
2014 442 16.00 483 17.50 in BCT compared with non-BCT in central and NAC
2015 437 15.90 555 20.10 tumors.
Age 0.114 One limitation of breast conserving surgery for cen-
< 45 233 8.50 244 8.90 tral breast cancer is postoperative aesthetics. In cases
45–59 1035 37.50 1101 39.90 of tumor involvement of the nipple-areola complex, the
60–79 1489 54.00 1412 51.20 surgeon may remove the nipple-areola complex to ensure
Race 0.527 a negative margin. This will bring great damage to post-
White 2202 79.90 2169 78.70 operative breast aesthetics. Overall, nipple areola com-
Black 254 9.20 274 9.90 posite reconstruction will improve patient satisfaction
Others 301 10.90 314 11.40 and confidence. With the development of plastic surgery,
Marital 0.287 a variety of methods of nipple areola composite recon-
Married 1713 62.10 1671 60.60 struction can be achieved, including tattooing, using
Single 405 14.70 446 16.20 synthetic materials, local flaps, and grafts [27–30]. This
Divorced 639 23.20 640 23.20 will make up for the shortcomings of breast conserving
Grade 0.669 surgery in central breast cancer. Priya et al. demonstrated
Grade I 585 21.20 569 20.60 for patients with central tumor treated with neoadju-
Grade II 1360 49.30 1406 51.00 vant chemotherapy, many patients may have successfully
Grade III 805 29.20 775 28.10 converted to nipple-areola complex after reevaluation at
Grade IV 7 0.30 7 0.30 the end of chemotherapy [31].
T stage 0.722 On the premise that the tumor safety and aesthetics
T1 1692 61.40 1676 60.80 can be achieved, breast conserving surgery for central
T2 918 33.30 948 34.40 breast cancer is a desirable option.
T3 85 3.10 79 2.90 We recognize several limitations of this study. First
T4 62 2.20 54 2.00 of all, this study is a retrospective study with inher-
N stage 0.547 ent flaws. Even though we use the PSM method, there
N0 1760 63.80 1799 65.30 will still be some biases. Secondly, because the patient’s
N1 843 30.60 815 29.60 BRCA gene information is not available, it is impossible
N2 108 3.90 107 3.90 to evaluate its impact on the breast cancer surgery in
N3 46 1.70 36 1.30 the central region. Third, there is no information about
ER status 0.579 postoperative complications, satisfaction and cos-
Negative 375 13.60 360 13.10 metic results of breast conserving surgery in our study.
Positive 2382 86.40 2397 86.90 Finally, the SEER database does not collect socioeco-
PR status 0.409 nomic and baseline health information, which may be
Negative 636 23.10 662 24.00
the relationship between surgical methods and survival.
Positive 2121 76.90 2095 76.00
In the absence of prospective high-level evidence, our
HER-2 status 0.458
current large-sample retrospective study is of great sig-
Negative 2316 84.00 2337 84.80
nificance to assess tumor safety, and more prospective
Positive 441 16.00 420 15.20
studies are needed in the future.
Liu et al. BMC Surgery (2022) 22:31 Page 9 of 11

A B
p<0.001 p<0.001

1.0 1.0

BCSS
OS

0.8 0.8
BCT
BCT
non-BCT non-BCT
0.6 0.6
0 20 40 60 80 100 0 20 40 60 80 100
Months Months
Fig. 3 Kaplan–Meier survival curves of overall survival and breast cancer-specific survival stratified by BCT and non-BCT in matched case–control
analysis (A: OS; B: BCSS)

A B C
p=0.018 p=0.009 p=0.004
1.0 1.0 1.0
OS

OS

0.8 0.8
OS 0.8

BCT BCT BCT

non-BCT non-BCT non-BCT
0.6 0.6 0.6

0 20 40 60 80 100 0 20 40 60 80 100 0 20 40 60 80 100

Months Months Months
Fig. 4 Kaplan–Meier survival curves of overall survival for BCT and non-BCT stratified by the stage in matched case–control analysis (A stage I;
B stage II; C stage III)

A B
p<0.001 p=0.037
1.0 1.0
OS

OS

0.8 0.8
BCT BCT
non-BCT non-BCT
0.6 0.6
0 20 40 60 80 100 0 20 40 60 80 100
Months Months
Fig. 5 Kaplan–Meier survival curves of overall survival for BCT and non-BCT stratified by the T stage in matched case–control analysis (A: T1–2; B:
T3–4)
Liu et al. BMC Surgery (2022) 22:31 Page 10 of 11

Conclusion treated with radical mastectomy or breast-conserving procedures:

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