Endoscopic mastectomy meta-analysis: commentary

Selection bias is an inherent limitation of all retrospective studies, including those evaluating conventional NSM. The suggestion that endoscopic NSM (E-NSM) included patients with more favourable tumour biology or anatomy is speculative and unsupported. In routine practice, surgical approach is determined not by tumour subtype or grade, but by anatomical feasibility, patient preference, and surgeon expertise. Moreover, all included comparative studies were assessed using the Newcastle Ottawa Scale to evaluate risk of bias (Supplementary Tables S4–S8).

Funnel plots and Egger’s tests were not applied due to the small number of studies per endpoint, consistent with PRISMA recommendations. These methods are unreliable with fewer than ten studies. Our search strategy was comprehensive and non-selective. The heterogeneity of findings further supports the absence of systematic bias in study inclusion.

Visual analogue scales (VAS) are validated and widely used to assess subjective outcomes in surgery, including cosmetic satisfaction. While not perfect, they provide reproducible and clinically relevant insights into patient perception, central in breast surgery. Though the BREAST-Q is a valuable tool, it has been predominantly applied in studies of minimally invasive approaches, with fewer direct comparisons to open NSM, limiting its utility in cross-technique analyses. Our meta-analysis included three studies reporting BREAST-Q “Satisfaction with Breast” scores (Supplementary Table S10), of which two showed significantly higher satisfaction in the E-NSM group. While image-based assessments may offer additional perspectives, they too are limited by variability in implementation and interpretation.

We acknowledge that E-NSM involves greater upfront resource use, longer operative times and specialized tools. However, a broader view is needed. Surgical innovation should not be evaluated solely by operative costs but by its overall value to the patient. For many young breast cancer survivors, improved body image and reduced visible scarring are not cosmetic extras, they are central to long-term recovery and psychosocial health. These benefits may reduce the need for revision procedures and promote adherence to survivorship care.Reduced complications, better aesthetic outcomes potentially reducing revisional surgeries and patient satisfaction are difficult to quantify but highly relevant in holistic care models. Until cost-effectiveness studies incorporate these dimensions, analyses focused solely on immediate hospital expenditure risk underestimating the long-term value of minimally invasive surgery.

The mean follow-up was up to 52.1 months in comparative studies, based on a population of 2,612 patients in the proportional meta-analysis and 656 patients in the pairwise meta-analysis. While longer-term data are always welcome, these durations provide the most robust evidence currently available and support the oncological safety of E-NSM.

More broadly, we believe this is an opportunity to shift the conversation. Surgical innovation should be guided not only by cost or operative metrics but by a comprehensive model of value-based care. Minimally invasive approaches may reduce surgical trauma, preserve body image, and enhance emotional well-being, especially in younger patients facing decades of survivorship. These outcomes are clinically meaningful and align with current healthcare priorities focused on improving patient-reported outcomes. We encourage future studies to include such endpoints when evaluating cost-effectiveness and clinical benefit.

We agree that further prospective studies, such as MARRES-3, are essential to consolidate the evidence base. However, based on our findings, we believe there is already sufficient data to support the use of E-NSM in routine clinical practice, beyond prospective research settings. Our meta-analysis is not without limitations. But it synthesizes the best available evidence to date and supports a balanced and patient-centered approach to adopting endoscopic NSM.