242 RECONSTRUCTION In the present survey, after mastectomy, we found that about two-thirds of physicians perform reconstruction in patients with EBC but only one-third do so in those with local breast cancer. Use of a pedicled transverse rectus abdominis myo- cutaneous flap was preferred after mastectomy. Reconstruction in patients with locally advanced breast cancer is less often performed than is the case in those with EBC. Most respon- dents use one of several plastic techniques to achieve better cosmetic results in EBC patients. These techniques include local tissue rearrangement, mesh application, and placement of a latissimus dorsi flap after breast-conserving surgery. Mesh application is popular, and is preferentially used in some Korean institutions. Precise indications for the application of mesh to a surgical site are needed and both the short- and long-term results require evaluation. SENTINEL LYMPH NODE BIOPSY In the present survey, over 80% of physicians perform addi- tional standard level I/II axillary lymph node dissection (ALND) if micrometastasis is evident, or when three or more sentinel lymph nodes are initially removed, whereas about 15% of phy- sicians do not perform standard level I/II axillary dissection. When the St. Gallen consensus conference met in 2011, most panels agreed to consider the omission of ALND completion for patients with isolated tumor cells who were scheduled for mastectomy or breast conserving surgery. However, the Panel also remarked very clearly, that the omission of completion of the ALND should not be extended more generally, to (for example) patients undergoing mastectomy, or to those not scheduled for whole-breast tangential field radiation therapy, or to those exhibiting involvement of more than two sentinel nodes, or to those receiving neoadjuvant therapy [13]. This survey clearly showed the disassociation between the guidelines actual clinical practice. As there is an increased level of evidence, respondents answered by treating the patient as recommended by the guidelines. For example, adjuvant chemo- therapy in early breast cancer has been well established higher level of evidences from large scale multicenter randomized clinical trials. In related questions, most respondents chose one or two standard therapies. However, the definition of the neg- ative margin in DCIS, secondary operation for the positive margin of DCIS, SLNB after neoadjuvant chemotherapy, and systemic therapy in recurrent or metastatic breast cancer are lacking a higher level of evidence. In related questions, answers from respondent demonstrate a wide spectrum of practices. Especially, the proportion of young women with breast cancer http://ejbc.kr Geumhee Gwak, et al. in Korea is higher than Western. This different epidemiology might affect the physicians’ decision to treat recurrent or met- astatic breast cancer in patients. Regardless of the recommen- dation of the guidelines, physicians have a tendency to choose more aggressive systemic cytotoxic therapy with several ex- pectations such as relief of pain, improving the quality of life, delaying the disease progression, and possibly curing of the disease. In Korea, the medical insurance system is relatively well organized and most cancer patients receive benefits which covers about 95% of the total cost for cancer therapy. This unique medical environment might affect the details of the KBCCPG. Although the effect of new innovative therapy was recently confirmed by an increased level of evidence, it takes times in Korea for medical insurance to cover the cost of new therapy. Consequently, the KBCCPG and the physicians’ prac- tices are affected by medical insurance and the health insur- ance review agency as another factor with the scientific evi- dences and cultural characteristics. LIMITATIONS AND PROSPECTIVE This survey demonstrated real clinical practices for breast cancer patients in Korea, but also exhibited several limitations. First, respondents who are mostly in their fourth or fifth de- cade as surgeons working in large hospitals were potentially represented bias in this survey. When we analyzed the answers after closing the online survey, most respondent were repre- sentative of younger surgeons. Consequently, the results were a representative opinion of specific groups within the KBCS regardless of the initial intention. This is far from the multidis- ciplinary politics of the KBCS and it could not demonstrate real circumstances of practice in Korea. Second, the question- naire in this survey is often arbitrary and the replied answers include very subjective factors that may have disturbed the objective analysis of the survey and demand more cautious interpretation. Third, respondents often skipped some essen- tial questions which were requested in the online survey and, in consequence, different denominators between each ques- tion may have caused confusion with the analysis of the results of the survey. Therefore, we keenly realized the necessity of a well organ- ized questionnaire for the focus on key issues through the process of this survey. However, we can predict the progress of the KBCS CPG by reason of persistent trials including official or unofficial discussions about clinical issues between the KBCS CPG panels, KBCS members, and third parties in various aca- demic circumstances. Furthermore, any feedback or query systems from guideline users might be seriously considered http://dx.doi.org/10.4048/jbc.2012.15.2.239