Comparison of radical mastectomy with alternative treatments for primary breast cancer. A first report of results from a prospective randomized clinical trial

DNA flow cytometric analysis of primary operable breast cancer. Relation of ploidy and S-phase fraction to outcome of patients in NSABP B-04

Between 1971 and 1974, 1665 women with primary operable breast cancer were randomized into a National Surgical Adjuvant Breast and Bowel Project (NSABP) trial (B-04) conducted to evaluate the effectiveness of several different regimens of surgical and radiation therapy. No systemic therapy was given. Cells from archival paraffin-embedded tumor tissue taken from 398 patients were analyzed for ploidy and S-phase fraction (SPF) using flow cytometry. Characteristics and outcome of patients with satisfactory DNA histograms were comparable to those from whom no satisfactory cytometric studies were available. In patients with diploid tumors (43%), the mean SPF was 3.4% +/- 2.3%; in the aneuploid population (57%), the SPF was 7.9% +/- 6.3%. Only 29.9% +/- 17.3% of cells in aneuploid tumors were aneuploid. Diploid tumors were more likely than aneuploid tumors to be of good nuclear grade (P less than 0.001) and smaller size (P equals 0.03). More tumors with high SPF were of poor nuclear grade than were tumors with low SPF (P equals 0.002). No significant difference in 10-year disease-free survival (P equals 0.3) or survival (P equals 0.1) was found between women with diploid or aneuploid tumors. Patients with low SPF tumors had a 13% better disease-free survival (P equals 0.0006) than those with a high SPF and a 14% better survival (P equals 0.007) at 10 years than patients with high SPF tumors. After adjustment for clinical tumor size, the difference in both disease-free survival and survival between patients with high and low SPF tumors was only 10% (P equals 0.04 and 0.08, respectively). Although SPF was found to be of independent prognostic significance for disease-free survival and marginal significance for survival, it did not detect patients with such a good prognosis as to preclude their receiving chemotherapy. The overall survival of patients with low SPF was only 53% at 10 years. These findings and those of others indicate that additional studies are necessary before tumor ploidy and SPF can be used to select patients who should or should not receive systemic therapy.

Significance of ipsilateral breast tumour recurrence after lumpectomy

Breast cancer treatment trials from the US National Surgical Adjuvant Breast and Bowel Project have established breast-conserving operations as a replacement for radical mastectomy (NSABP B-04), and have shown that in terms of survival free from distant disease there was no significant difference between lumpectomy, lumpectomy plus breast irradiation, and total mastectomy (NSABP B-06). 9-year follow-up data from B-06 are used here to address the issue of ipsilateral breast tumour recurrence (IBTR) and the development of distant disease, a question with important clinical and biological implications. A Cox regression model on fixed co-variates (ie, features such as tumour type or size present at surgery and not subsequently alterable) and on IBTR, which is time dependent and not fixed, revealed that the risk of distant disease was 3.41 times greater after adjustment for co-variates in patients in whom an IBTR developed. IBTR proved to be a powerful independent predictor of distant disease. However, it is a marker of risk for, not a cause of, distant metastasis. While mastectomy or breast irradiation following lumpectomy prevent expression of the marker they do not lower the risk of distant disease. These findings further justify the use of lumpectomy.

[Breast saving therapy in the small breast cancer]

According to the satisfying results reported by Fisher, Veronesi and other authors who used a breast-conserving operation modality in the treatment of breast cancer since 1980 109 patients with a carcinoma up to 2.5 cm underwent this kind of operation at the surgical department of the Hanusch-Hospital, Vienna. Although the median follow-up-time (29 months) is too short for conclusive statements, results of recurrence and survival compared to 162 cases of modified radical mastectomy were satisfying. Therefore--following certain indications--breast conserving operation is offered to our patients as a possible method.

Modern thoughts on lymph nodes in breast cancer

Axillary lymph node status remains the single most useful prognostic parameter in breast cancer patients. As clinical examination, imaging techniques, and lymph node sampling methods cannot accurately assess the axillary node involvement, a complete axillary dissection should always be performed. Moreover, this technique provides an excellent treatment modality for regional disease, abolishing the need for radiotherapy to the axilla. The status of the internal mammary lymph nodes is of less importance in the management of the breast cancer patient.

The significance of regional lymph node dissection in the surgical management of breast cancer

The results of an analysis done on the regional lymph node metastases of 300 patients with operable breast cancer, who were treated in the Department of Surgery (II), Kanazawa University Hospital from 1973 to early 1988 are reported herein. It was found that the metastases of the axillary and internal mammary lymph nodes were closely related to the survival of patients, but they were hardly diagnosed before the operation. Only the dissection of these lymph nodes proved useful for providing the prognostic information. Moreover, in a retrospective study comparing the en bloc extended radical mastectomy versus the other types of mastectomy, the extended radical mastectomy was seen to greatly improve the survival of patients with 3 or less than 3 metastatic axillary lymph nodes. Thus, the extended radical mastectomy provides the maximum diagnostic and prognostic information, and gives the best chance of loco-regional control of the disease. The anterior chest deformity created by the extended radical mastectomy, however, should be avoided in those patients without internal mammary involvement. We therefore propose the modified extended mastectomy as a staging operation.

Management of elderly patients with primary breast cancer

From 1974 through 1983, three hundred forty-three patients aged 70 years or older at diagnosis received comprehensive post-operative radiation therapy for localized (Stage I-III) breast cancer following surgical procedures ranging from incisional biopsies to classical radical mastectomy. The 5- and 10-year overall survival rates for this series of elderly patients are 67% and 33%. The respective disease-free survival rates are 67% and 42%. Over one-half of these women were treated by less than total mastectomy. No differences were seen in survival, disease-free survival, or local regional control rates comparing similarly staged patients treated by radical mastectomy, modified radical mastectomy, or tylectomy. Complications were few and seen primarily in those patients subjected to axillary dissection prior to irradiation. Long term survival appears to be achievable in the majority of elderly patients with regionally confined disease at presentation and aggressive treatment with curative intent is warranted. These elderly patients are often poor candidates for radical surgery. In this patient population, conservative surgery with post-operative radiation therapy is well tolerated and provides equivalent results to more radical surgical procedures.

Conservative treatment of early breast cancer

At our Institution, the treatment policy for early carcinoma of the breast (T1-2, NO, AJC) is lumpectomy followed by radiotherapy to the breast and peripheral lymphatics. From October 1976 until December 1982, 171 patients have been admitted and treated. Radiotherapy was administered with 60 Co, 5.000 cGy in 5 weeks to the breast and lymphatics plus a boost to the scar giving q.s.p. 6.400 cGy at maximum tumor depth. With a minimum follow-up of 3 years and a median follow-up of 61.7 months the locoregional control was 94.2% and survival at 8 years with no evidence of disease (NED) was 77.2% with an overall survival rate of 90%. No difference in NED survival rate was found between Stage I and II. There was a tendency to better survival rate in those patients older than 50 years and also for post menopausal patients, however the difference did not reach statistical significance (66.7% NED survival at 8 years for premenopausal and 81.8% NED survival for post menopausal, also at 8 years, p = 0.056 Gehan). The time elapsed between surgery and radiation therapy (between 1 and 2 months) was found to be nonsignificant. Only 1 out of 171 patients had axillary dissection. The importance or lack of it, is discussed.

The case against the surgical concept of en bloc dissection for certain malignancies of the reproductive tract

The en bloc dissection approach to many cancers of the reproductive tract needs re-evaluation in light of recent data. The mechanisms by which one or more malignant cells leaves the primary lesion and are then deposited as a viable focus at distant sites, is also in need of study. The hypothesis is put forth that metastases to regional lymph nodes occurs from the primary lesion as an embolic event leaving the intervening normal tissue bridge at low risk for disease. Indeed, these viable cells, which have the potential for becoming a metastatic focus, may fall victim to the patient's host defense mechanisms. In light of this, recent clinical experience with cancer of the cervix, vulva, and breast, is outlined with particular emphasis on more conservative surgical techniques and their success. A plea is made for individualization of surgical therapy, especially with early lesions affording ample opportunities for preservation of function, body image, and improved quality of life.

Five year results of radical mastectomy for breast cancer, by a sternal splitting, intrapleural en bloc resection of the internal mammary lymph nodes

A new operative method of extended radical mastectomy enables complete resection of the axillary and internal mammary lymph nodes. In this paper, we present the histological analysis of the internal mammary involvement, and the estimated 5 year survival rate, of 100 patients with breast cancer of Stage I, II or III, who underwent this operation. The incidences of axillary and internal mammary involvements were 41 per cent and 17 per cent, respectively. The metastases in the internal mammary lymph node chain were located from just below the supraclavicular vein to the third intercostal space along the internal mammary vessels. The types of lymphatic invasion observed in the internal mammary chain were lymph node metastases in 88 per cent, metastatic lesion in the lymphoid tissue in 29 per cent and cancer cell emboli in the lymphatic channel in 71 per cent. The overall estimated 5 year survival rate was 90.5 per cent. Where there was internal mammary involvement, the estimated 5 year survival rates for those with no axillary lymph node metastasis, those with fewer than 3 metastatic axillary lymph nodes, and those with more than 4 metastatic axillary lymph nodes were 100 per cent, 80 per cent and 31.2 per cent, respectively. Although the assumption that more aggressive surgical removal of the primary lesion and the regional lymphatic spread gives a higher cure rate has not been proved, this extended radical mastectomy with adjuvant chemoendocrine therapy seems to give a higher 5 year survival rate for patients with internal mammary involvement.

Comparative study of long-term effects of surgical excision and excision combined with radiotherapy or chemotherapy in breast cancer: an analysis of 192 cases

Clinical data of 192 patients with breast cancer with a primary lesion of 2-5 cm (stage II according to the criteria recommended by the UICC) and with histopathologically confirmed positive axillary lymph nodes were analyzed. The patients were divided into three groups: 1) surgical excision alone; 2) surgery plus irradiation; and 3) surgery plus chemotherapy. It was shown that the 5-year survival rates for these groups were 40.5%, 61.0%, and 62.0%, respectively (P less than .05).

Edema of the arm as a function of the extent of axillary surgery in patients with stage I-II carcinoma of the breast treated with primary radiotherapy

Edema of the arm can be a significant complication following treatment of breast cancer. To determine the risk of arm edema and factors associated with this risk in patients treated with primary radiotherapy, we reviewed the records of 475 women with early breast cancer treated between 1968 and 1980. During this period, the use of axillary surgery prior to radiation gradually increased, and all patients received full axillary irradiation until late in the series. Based on the surgeon's report, the extent of axillary surgery was classified as either a sampling, a lower dissection, or a full dissection. Edema of the arm was scored on clinical grounds and ranged from mild hand swelling to an increased arm circumference of 8 cm. At 6 years, the actuarial risk of developing arm edema was 8% for the entire study population. This risk was 13% for 240 patients who had axillary surgery and 4% for 235 patients not undergoing axillary surgery (p = 0.006). For patients undergoing axillary surgery, the risk of arm edema was 37% with full dissection compared to 5% with sampling (p = 0.0003), and 8% with lower dissection (p = 0.03). The risk of arm edema at 6 years was 28% if more than ten nodes were removed, and 9% if one to ten nodes were removed (p = 0.03). However, the extent of axillary dissection was stronger predictor of subsequent edema than was the number of nodes obtained. The role of axillary irradiation could not be evaluated since 91% of patients received axillary irradiation. The use of chemotherapy, the site or size of the primary tumor, clinical nodal status, patient age and weight, type of suture, the use of a drain, and subsequent local or distant failure did not appear to be significant risk factors. We conclude that the combination of full dissection and full axillary irradiation results in an unacceptably high risk of arm edema.

Local recurrences in patients with breast cancer at the North Carolina Memorial Hospital (1970-1982)

A study of predictive factors for locoregional recurrences after curative surgery for breast cancer was undertaken. Specifically, the authors wished to determine whether such recurrences correlated with either hormonal receptor status or a delay between the initial biopsy and the definitive surgery. A retrospective chart review was done on all women with breast cancer who had surgery for cure between 1970 and 1982. Factors analyzed included, among others, size of the tumor, clinical and pathologic status of the axilla, estrogen and progesterone receptors status, and delay between biopsy and definitive surgery. There were 404 patients studied. Pathologic axillary nodal status was the most important predictor of locoregional recurrence, with failures in 36 of 188 (19%) node-positive but only 9 of 216 (4%) node-negative patients (P = 0.0001). In node-positive patients, tumor size was a predictor of local recurrence, with failure in only 4 of 51 (8%) of tumors less than 2 cm, but in 14 of 44 (32%) of tumors greater than 6 cm (P = 0.004). Progesterone receptor (PR) status correlated with locoregional recurrence, but estrogen receptor status did not. In node-positive women, there were 4 of 14 PR-negative but 0 of 15 PR-positive local failures (P = 0.017); this result has not been previously reported. The presence of palpable axillary disease was also found to be a predictor of local recurrence. Finally, no increase in locoregional recurrence could be attributed to the delay between biopsy and definitive surgery. Two new predictors for locoregional recurrence in breast cancer, not previously emphasized, are PR and clinical axillary status. Should these findings be substantiated, patients at high risk for locoregional recurrence could then be more readily identified.

Planning of Ir-192 seed implants for boost irradiation to the breast

The conservative management of early stage breast cancer with tumor excision and irradiation of the breast is becoming increasingly accepted as an alternative to modified radical mastectomy. The radiotherapy typically consists of 45 to 50 Gy delivered with external beam irradiation, followed by boost irradiation of 15 to 20 Gy to the tumor bed using electron beams or interstitial implantation. Pathological evaluation of the excised tumor, clinical assessment, and mammography are used to determine the tissue volume potentially containing a residual tumor burden and therefore requiring boost irradiation. In this paper we describe planning and implantation procedures for Quimby-type breast implants using Ir-192 seeds encapsulated in nylon tubing. This system deviates in several important respects from the requirements of the standard brachytherapy systems. For double-plane implants, optimized values of the interplanar spacing are given for a range of implant sizes, along with the corresponding target dose rates for 1.0 mCi seeds. We also describe a modification of the angiocatheter implantation technique, which allows the radioactive sources to be secured in place by a magnetic cap and washer, thus greatly facilitating the removal of the sources at the end of treatment.

Modern surgical treatment of breast cancer

Since the 1950's the treatment of breast cancer has changed substantially. This related surgery has become less disfiguring without either impairing survival or increasing recurrences. Adjuvant chemotherapy has also contributed.

Local regional effectiveness of surgery and radiation therapy in the treatment of breast cancer

Although gross tumor can be controlled with high doses of radiation therapy, control is achieved at the expense of severe radiation sequelae. In order to improve tumor control with minimum complications, the field of treatment should contain only subclinical disease. This article reviews the successful combination of surgery for the removal of gross cancer and radiation of moderate dose for the treatment of subclinical disease in patients with breast cancer. In patients with clinically favorable and operable disease, the combination of a radical or modified radical mastectomy and postoperative radiation therapy of 5000 rad to the peripheral lymphatics and chest wall can secure 90% of the treated areas. For patients with locally and regionally advanced breast cancer, the combination of a simple mastectomy and dissection of the lateral axilla followed by postoperative irradiation of 5000 rad in 5 weeks to the chest wall, axilla, and peripheral lymphatic areas will control more than 85% of the patients treated as compared with approximately 70% control when surgery or radiotherapy alone is used, even with chemotherapy. Yet another clinical application of the subclinical disease concept is the successful combination of conservation surgery (whether segmental mastectomy, quadrantectomy, or wide excision) for gross tumor in the breast and axilla and irradiation for residual microscopic and multiple foci of tumor, yielding more than 90% control of locoregional disease with survival rates equal to those patients treated with radical or modified radical mastectomy. Results of multiple clinical trials and reported series are reviewed.

Long-term survival and prognostic factors in patients with regional breast cancer (skin, muscle, and/or chest wall attachment)

Between 1948 and 1981, 1230 patients were diagnosed as having regional (skin, muscle, or chest wall attachment) breast cancer, and long-term survival was studied. In all patients, overall survival was 33% at 5 years, 19% at 10 years, and 9% at 20 years. Significant excess mortality due to breast cancer was observed throughout the 20-year follow-up period (P less than 0.002). The risk of breast cancer was highest in the 5-year period following diagnosis, and declined steadily from that time. Additionally, 308 patients diagnosed since 1968 were studied for the effect of prognostic factors. Clinical status of nodes (positive or negative) and presence or absence of peau d'orange were found to be significant prognostic factors in those patients. In those receiving radical surgery, the number of nodes and presence or absence of peau d'orange were found to be of prognostic significance. No effect of race, age, year of diagnosis, site of attachment, type of fixation, ulceration, edema, size of tumor, satellite nodules, or dimpling retraction on breast-cancer-specific survival was observed when the nodal status and peau d'orange were controlled. These data demonstrate that mortality in regional breast cancer is significant and is highly dependent on peau d'orange and nodal status.

Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation

In 1971 we began a randomized trial to compare alternative local and regional treatments of breast cancer, all of which employ breast removal. Life-table estimates were obtained for 1665 women enrolled in the study for a mean of 126 months. There were no significant differences among three groups of patients with clinically negative axillary nodes, with respect to disease-free survival, distant-disease--free survival, or overall survival (about 57 per cent) at 10 years. The patients were treated by radical mastectomy, total ("simple") mastectomy without axillary dissection but with regional irradiation, or total mastectomy without irradiation plus axillary dissection only if nodes were subsequently positive. Similarly, no differences were observed between patients with clinically positive nodes treated by radical mastectomy or by total mastectomy without axillary dissection but with regional irradiation. Survival at 10 years was about 38 per cent in both groups. Our findings indicate that the location of a breast tumor does not influence the prognosis and that irradiation of internal mammary nodes in patients with inner-quadrant lesions does not improve survival. The data also demonstrate that the results obtained at five years accurately predict the outcome at 10 years. We conclude that the variations of local and regional treatment used in this study are not important in determining survival of patients with breast cancer.

Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer

In 1976 we began a randomized trial to evaluate breast conservation by a segmental mastectomy in the treatment of Stage I and II breast tumors less than or equal to 4 cm in size. The operation removes only sufficient tissue to ensure that margins of resected specimens are free of tumor. Women were randomly assigned to total mastectomy, segmental mastectomy alone, or segmental mastectomy followed by breast irradiation. All patients had axillary dissections, and patients with positive nodes received chemotherapy. Life-table estimates based on data from 1843 women indicated that treatment by segmental mastectomy, with or without breast irradiation, resulted in disease-free, distant-disease-free, and overall survival at five years that was no worse than that after total breast removal. In fact, disease-free survival after segmental mastectomy plus radiation was better than disease-free survival after total mastectomy (P = 0.04), and overall survival after segmental mastectomy, with or without radiation, was better than overall survival after total mastectomy (P = 0.07, and 0.06, respectively). A total of 92.3 per cent of women treated with radiation remained free of breast tumor at five years, as compared with 72.1 per cent of those receiving no radiation (P less than 0.001). Among patients with positive nodes 97.9 per cent of women treated with radiation and 63.8 per cent of those receiving no radiation remained tumor-free (P less than 0.001), although both groups received chemotherapy. We conclude that segmental mastectomy, followed by breast irradiation in all patients and adjuvant chemotherapy in women with positive nodes, is appropriate therapy for Stage I and II breast tumors less than or equal to 4 cm, provided that margins of resected specimens are free of tumor.

A randomized controlled trial of prophylactic cytotoxic chemotherapy in potentially curable breast cancer

A randomized controlled trial of the value of oral adjuvant cytotoxic chemotherapy in the treatment of potentially curable breast cancer has been in progress in the Oxford Region since 1977. Eighty-seven patients were allocated to treatment with melphalan 0.2 mg/kg for 5 consecutive days every 6 weeks for 2 years; 98 patients were allocated to treatment with oral combination therapy consisting of melphalan 10 mg daily for 5 consecutive days, plus methotrexate 15 mg and 5-fluorouracil 250 mg on the first day, courses being repeated every 6 weeks for 2 years; and 88 patients were allocated to a control group which received no adjuvant chemotherapy. So far, 125 patients have suffered a recurrence of breast cancer and 85 have died. No statistically significant differences in outcome are apparent between the three treatment groups, although there is some indication of a beneficial effect of chemotherapy on disease-free interval in pre-menopausal women. Toxic effects of treatment, notably nausea, vomiting and bone marrow depression, have been moderately severe. In our view, the beneficial effects of current adjuvant cytotoxic chemotherapy, if any, are too modest to justify the suffering which such treatment can cause at a time when a woman with breast cancer might otherwise expect to feel physically well.

The clinical significance of minimal breast cancer: a pathologist's viewpoint

We can draw the following conclusions about minimal breast cancer: The concept of minimal breast cancer as a stage of cancer that is 95% curable is a valid one, if minimal breast cancer is defined by strict parameters. Both 0.5 and 1.0 cm have been defined as the upper limit of size for minimal invasive cancer. Some data indicate that 0.5 cm is the preferable dividing line and that 1-cm cancers are no longer minimal. Other data suggest that the most important factor is axillary lymph node status. One-centimeter cancers are probably 95% curable if axillary lymph nodes are negative. Cancers of 0.5 cm and smaller in size are probably not 95% curable if axillary lymph nodes are involved. Carcinoma in situ appears to be highly curable, even if axillary lymph nodes are involved. Minimal breast cancer should include lobular carcinoma in situ (lobular neoplasia) and ductal carcinoma in situ regardless of nodal status, and (tentatively) invasive carcinoma smaller than 1 cm in total diameter, if axillary lymph nodes are not involved. Many cases of minimal breast cancer are asymptomatic. If special screening is not used, less than 10% of women with breast cancer will be at the minimal stage when diagnosed. Screening programs can increase this ratio to as much as one third of patients, perhaps even more. While serious questions about cost effectiveness of mass screening remain, screening programs appear to represent the best way of detecting minimal breast cancer. Screening programs should include careful history and physical examination, of course. The role of mammography is still controversial. It is probable that at least 50% of all minimal cancers would be missed without mammography. After a period of significant worry about the risk of radiation, opinion seems to be changing now and many authors are willing to accept the fact that mammography is of more benefit than risk for younger women. The HIP study would indicate that the risk/benefit ratio becomes favorable at age 50. Many authorities would now comfortably include mammography in the screening of women age 40 or older. Some authors believe that the benefits of mammography outweight the risks for patients of all ages. This question needs to be tested, and several randomized prospective clinical trials now in progress are doing just that. The legitimate worry over the risks of mammography should not obscure a very important fact.(ABSTRACT TRUNCATED AT 400 WORDS)

Conservation surgery and irradiation as an alternative to mastectomy in the treatment of clinically favorable breast cancer

The combination of conservation surgery and radiation therapy for early breast cancer is gaining acceptance as an alternative to radical mastectomy. This article reviews the results of randomized trials showing that there is no advantage to a radical mastectomy in patients with early breast cancer. In addition, the article will review multiple reports concerning the local and regional tumor control and survival of patients treated with conservation surgery and irradiation as well as a comparison of 1073 patients with TIS T1 T2 N0 N1 breast cancer treated at University of Texas (UT) M. D. Anderson Hospital between 1955 and 1980, of whom 345 were treated with conservation surgery and irradiation and 728 were treated with radical or modified radical mastectomy alone. The locoregional recurrence in the patients treated with an intact breast is 4.9%, and 5.6% in patients treated with radical or modified radical mastectomy. There is no significant difference in the 10-year disease-free survival rates between the two groups of patients. In addition, a comparison of 2467 patients with Stage I and Stage II breast cancer treated at the UT M. D. Anderson Hospital shows no significant difference in the incidence of consecutive second breast carcinoma as a result of the use of radiation therapy in the treatment of the first breast cancer.

Partial mastectomy without radiation therapy

Partial mastectomy without radiation therapy has been used at The Cleveland Clinic as a treatment option for selected patients with breast cancer since 1957. Our experience with 322 patients has been reviewed; survival results are equal to or better than the other operative procedures we have employed for the treatment of breast cancer. These results, we believe, relate more to the selection of patients with small tumors and at a more favorable stage of the disease than to the benefit of the operative procedure itself.

The impact of pathology on the biologic, diagnostic, prognostic, and therapeutic considerations in breast cancer

It has become readily appreciated that an understanding of the pathologic aspects of breast cancer is essential to the planning of many clinical trials. The clinical findings obtained from such studies unquestionably served as a stimulus for other relevant pathologic investigations but did not always resolve all of the long-standing pathologic problems associated with the diagnosis of breast diseases. This article addresses some of the pathologic problems that have a bearing on the biologic, diagnostic, prognostic, and therapeutic aspects of breast cancer.

Surgery and radiotherapy for primary breast cancer. What we have learned from the controlled clinical trials

The history of the use of surgery and radiotherapy for the management of primary breast cancer is reviewed with an emphasis on the conclusions to be reached from the controlled clinical trials. Prophylactic treatment of clinically negative regional nodes by either surgical extirpation or radiotherapy does not improve survival in comparison with a policy of observation and treatment at the time of clinical progression. Axillary node dissection is currently important for histologic staging of the axillary nodes. Early results of the controlled trials appear to support the concept that for selected patients, a regimen of complete excision of the primary tumor and breast irradiation produces results equivalent to those of total mastectomy in terms of distant recurrence and survival.

Selective avoidance of lymphatic irradiation in the conservative management of breast cancer

High-dose lymphatic irradiation is a contributory factor to the morbidity of treatment after local excision and high-dose radiotherapy for early stage breast cancer and may detract significantly from the cosmetic result. The apparent inability of lymphatic irradiation to influence the survival of patients with early stage breast cancer supports an argument for the selective avoidance of regional radiotherapy in a proportion of patients. Based on a review of the effects of lymphatic radiotherapy on lymphatic control, complications, cosmesis, survival and the effects of withholding lymphatic irradiation, recommendations are made for the selective treatment of patients at high risk of regional recurrence. In patients submitted to full axillary dissection, node negative patients require no lymphatic irradiation. After full axillary dissection radiotherapy is confined to the supraclavicular fossa in patients with heavy axillary involvement. A policy for patients having limited axillary dissection is discussed which identifies approximately 50% of patients as eligible for careful watch policy following local excision and high-dose radiotherapy to the primary disease.

Benefits versus risks in conservation surgery with irradiation for breast cancer

This report analyzes the survival and complications inherent in the conventional treatment of breast cancer, radical mastectomy, and the more conservative procedure, conservation surgery with irradiation. Both procedures have benefits and risks. The benefits as measured by survivorship appear to be approximately the same. The major benefit of conservation surgery with irradiation is that the breast is left intact. The possible complication of irradiation carcinogenesis is addressed, and the literature analyzed. This review indicates that the absolute risk of breast cancer developing in the second breast is not nearly as great as originally thought. It is concluded that if a woman with breast cancer is a candidate for either mastectomy or the conservative procedure, it is the clinician's obligation to objectively present the evidence regarding the benefits and risks of these procedures.

Physicians' reasons for not entering eligible patients in a randomized clinical trial of surgery for breast cancer

We studied the reasons surgical principal investigators chose not to enter patients in a large, multicenter trial sponsored by a cooperative group. In 1976 the National Surgical Adjuvant Project for Breast and Bowel Cancers (NSABP) initiated a clinical trial to compare segmental mastectomy and postoperative radiation, or segmental mastectomy alone, with total mastectomy. Because the low rates of accrual were threatening to close the trial prematurely, we mailed a questionnaire to the 94 NSABP principal investigators, asking why they were not entering eligible patients in the trial. A response rate of 97 per cent was achieved. Physicians who did not enter all eligible patients offered the following explanations: (1) concern that the doctor-patient relationship would be affected by a randomized clinical trial (73 per cent), (2) difficulty with informed consent (38 per cent), (3) dislike of open discussions involving uncertainty (22 per cent), (4) perceived conflict between the roles of scientist and clinician (18 per cent), (5) practical difficulties in following procedures (9 per cent), and (6) feelings of personal responsibility if the treatments were found to be unequal (8 per cent). Further investigation into the behavioral aspects of the investigator-patient relationship is particularly pressing, since fear of change in this relationship was the most common reason given for not entering eligible patients in the trial.

Breast cancer in association with lobular carcinoma in situ. Clinicopathologic review and treatment recommendation

A 6 year follow-up study of 80 women with coexisting lobular carcinoma in situ and infiltrating breast cancer has been conducted to emphasize the natural history and management of these cancers. Treatment of the contralateral breast is of utmost importance as lobular carcinoma in situ is a multicentric neoplasm associated with a subsequent high occurrence of invasive cancer. This series has documented a high incidence of bilateral cancer. Six patients (7.5 percent) had simultaneous bilateral tumors and eight patients (10 percent) had the subsequent development of a second primary tumor, representing approximately four times the expected rate. Despite a well structured out-patient department, follow-up was suboptimal. Six of eight metachronous tumors were detected at a late stage (T2 and greater).

Lucy Wortham James Lecture. Subclinical disease

A number of patients with cancer later develop metastases in the draining lymphatics, which initially were clinically negative. These occult deposits represent subclinical disease in lymphatic areas accessible to palpation, like the neck, axillae, and groin. The concept applies also to the microscopic disease left in an area after a surgical procedure is known to have removed all gross cancer, yet some patients later develop a recurrence. The term "subclinical disease" refers only to disease in a specific anatomic area, based on clinical facts. Radiobiological parameters account for the fact that subclinical disease requires less irradiation to be eradicated than gross cancer. The concept has two main applications, elective irradiation of clinically negative peripheral lymphatics and locoregional irradiation combined with surgery, which are determined by site and disease. The concept of subclinical disease also has implications for chemotherapy, which bear a direct relationship between chemotherapy both with radiation therapy and surgery.

Surgical clinical trials

Surveys of surgical practice in the United States during the last 2 decades have documented a gradual retreat from the standard radical mastectomy for treatment of early breast cancer. During this time, clinical trials have tested traditional principles of cancer surgery, and permitted conclusions to be made regarding treatment alternatives. Modified mastectomy (total mastectomy plus axillary dissection) has proved equal to radical mastectomy in terms of survival, disease-free survival, and local tumor control in a randomized trial confined to TNM clinical Stage I and II cases. This study showed that routine removal of grossly uninvolved pectoral muscles (and apical axillary nodes) is not necessary in early cases, a result which failed to support the principle of en bloc dissection. Trials addressed to the practice of prophylactic regional node dissections have indicated that node dissections are useful for reducing regional tumor recurrence, for providing prognostic information, and for establishing the need for adjuvant treatment, but they do not improve overall survival. Metastases in lymph nodes appear to be a sign, rather than a source, of tumor dissemination. Furthermore, a recent trial indicates that routine removal of the breast may not be necessary in early cases. High-dose irradiation of the breast (after wide excision of the primary and axillary dissection) in TNM clinical Stage I cases provided local tumor control and survival comparable to that of radical mastectomy. Trials of breast preservation not yet complete address more advanced stages (TNM I and II), and the question of whether irradiation is necessary in all cases. On the basis of completed studies, it appears that TNM clinical State I and II cancers can be appropriately treated with modified mastectomy; Stage I cancers can be treated equally well with irradiation of the breast after quadrantectomy and removal of axillary lymph nodes.

Clinical studies on the use of radiation therapy as primary treatment of early breast cancer

The treatment of operable breast cancer by primary radiation therapy instead of mastectomy is undergoing evaluation in the United States and Europe. Retrospective studies of patients treated by primary radiation therapy show that local control and survival rates are comparable to those obtained by mastectomy. Detailed analysis of local failure following primary radiation therapy indicates the importance of excisional biopsy of the primary tumor, moderate doses of radiation to the breast and draining lymph node areas, and the use of a boost to the primary tumor area in maximizing local control. Further, the judicious use of local excision combined with meticulous radiotherapy technique yields highly satisfactory results for the majority of treated patients. Preliminary results from prospective trials also indicate that primary radiation therapy provides both local control and survival rates equivalent to mastectomy. Primary radiation therapy is becoming an increasingly important alternative to mastectomy where surgical and radiotherapeutic expertise are available to optimize both local tumor control and the final cosmetic outcome.

The metastasis-free interval following curative treatment for breast cancer

Although much research has been done to isolate factors that have good prognostic value for cure in breast cancer, comparatively little attention has been paid to the large variation in the metastasis-free interval (MFI) in those who are not cured. In this paper we studied 247 patients who were given curative treatment for breast cancer, all of whom developed metastatic disease. The MFI varied from 2 months to 22 years and was found to depend on nodal status, initial T-stage, and possibly, location of the tumor within the breast; it did not depend on age of the patient or histologic appearance of the tumor. In addition, the time from first relapse to death did not correlate with the MFI. With one exception (brain) the initial site of distant metastasis was the same in late relapsers as in early relapsers.

Risk of internal mammary lymph node metastases and its relevance on prognosis of breast cancer patients

The risk of internal mammary chain metastases according to some parameters and its prognostic relevance was evaluated on the basis of the experience collected at the National Cancer Institute of Milan where, from January 1965 to December 1980, 1085 patients were submitted to Halsted mastectomy plus internal mammary chain dissection. A multivariate analysis was carried out, resorting to a multiple linear regression with logistic transformation of the dependent variable. The selection of prognostic factors has been performed with a step-down approach. The frequency of metastases to internal mammary chain nodes was evaluated according to four criteria: age, site and size of primary tumor, and presence of axillary metastases. Data of this series indicate that the frequency of internal mammary node metastases is significantly associated with the age of the patients (younger patients have a higher risk) (p = 0.006) with the size of primary tumor (p = 0.006) with the presence of axillary node metastases (p = 10(-9). Patients with both axillary and internal mammary positive nodes have a very poor prognosis (10-year survival 37.3%) while patients with either axillary metastases only or internal mammary metastases only have an intermediate less grave prognosis (59.6% and 62.4%, respectively). As regards the risk of internal mammary nodes involvement, it appears that knowing the age, the size, and the axillary nodes status, it is possible to calculate with good approximation the probability of their invasion.

Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update

The current findings completely affirm the validity of our original observations indicating the appropriateness of grouping primary breast cancer patients into those with negative, 1 to 3, or greater than or equal to 4 positive nodes. Results, however, reveal that there is a risk in combining all patients with greater than or equal to 4 positive nodes into a single group. Since there was a 25% greater disease-free survival and an 18% greater survival in those with 4 to 6 than in those with greater than or equal to 13 positive axillary nodes, such a unification may provide misleading information regarding patient prognosis, as well as the worth of a therapeutic regimen when compared with another from a putatively similar patient population. Of particular interest were findings relating the conditional probability, i.e., the hazard rate, of a treatment failure or death each year during the 5-year period following operation to nodal involvement with tumor. Whereas the hazard rate for those with negative, or 1 to 3 positive nodes, was relatively low and constant, in those with greater than or equal to 4 positive nodes the risk in the early years was much greater, but by the fifth year it was similar to that occurring when 1-3 nodes were involved, and not much different from negative node patients. The same pattern existed whether 4 to 6 or greater than or equal to 13 nodes were positive. When the current findings are considered relative to other factors with predictive import, it is concluded that nodal status still remains the primary prognostic discriminant.

Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update

The current findings completely affirm the validity of our original observations indicating the appropriateness of grouping primary breast cancer patients into those with negative, 1 to 3, or greater than or equal to 4 positive nodes. Results, however, reveal that there is a risk in combining all patients with greater than or equal to 4 positive nodes into a single group. Since there was a 25% greater disease-free survival and an 18% greater survival in those with 4 to 6 than in those with greater than or equal to 13 positive axillary nodes, such a unification may provide misleading information regarding patient prognosis, as well as the worth of a therapeutic regimen when compared with another from a putatively similar patient population. Of particular interest were findings relating the conditional probability, i.e., the hazard rate, of a treatment failure or death each year during the 5-year period following operation to nodal involvement with tumor. Whereas the hazard rate for those with negative, or 1 to 3 positive nodes, was relatively low and constant, in those with greater than or equal to 4 positive nodes the risk in the early years was much greater, but by the fifth year it was similar to that occurring when 1-3 nodes were involved, and not much different from negative node patients. The same pattern existed whether 4 to 6 or greater than or equal to 13 nodes were positive. When the current findings are considered relative to other factors with predictive import, it is concluded that nodal status still remains the primary prognostic discriminant.

Considerations of cost and effectiveness in the choice of mastectomy

Operable breast cancer may be managed equally well by a number of different regimens of mastectomy and/or radiotherapy. This paper examines the financial and morbidity costs, together with the node sampling efficacy, of three commonly employed techniques: simple mastectomy; total mastectomy with node biopsy or limited node excision; and modified radical mastectomy. Adjuvant radiotherapy (and/or chemotherapy) can only be applied rationally if node sampling is effective. Simple mastectomy cannot achieve this. Total mastectomy, providing that a node sample is obtained, is effective, and is probably the cheapest option. Total axillary clearance runs the risk of increased morbidity (and financial cost), while not necessarily guaranteeing more effective node sampling. Much of the cost and morbidity of mastectomy may be reduced by a limited but rational radiation policy.

Current concepts in radiotherapy and their impact on oncology

The constant emphasis on the need for breakthroughs and new modalities of treatments seems to imply that nothing has been achieved, and unless new beams or radiation sensitizers or whatever are discovered, radiation therapy is ineffective. A great amount of information has been acquired in the past 20 years, and innumerable treatment schemes are being used with doubtful outcomes. The fact that patients are at high risk for development of distant metastases is irrelevant if one does not have a treatment that is effective. Multimodality treatments are very popular, but multimodality per se does not make a treatment effective. Medical research is anxious for early and repeated milestones. Cancer is a disease that requires follow-up and, in some areas, like breast cancer, a long follow-up. Baclesse, the great radiotherapist from the Curie Foundation, used to say in his teaching clinics that he was working for the next generation. Radiotherapy exists within the framework of medical practice. To emphasize systemic treatments because of the possibility of distant metastases and, by so doing, to deemphasize freedom of disease in the local area leads to abandoning methods of treatment that have proved effective for control of local-regional disease. An example is the abandonment of postoperative irradiation following mastectomy. It is not disputed that it achieves a very high degree of local and regional control, but it is disputed that it increases survival. Survival benefits with elective chemotherapy are marginally proved in small subsets of patients but do not demonstrably affect the survival rates of the overall population, and there is very little information concerning the local-regional control with elective chemotherapy. Survival benefits are not the only criteria of usefulness of a treatment. Gross recurrence is more difficult to eradicate than subclinical disease by elective irradiation, and there are a number of publications on the poor control of local-regional recurrences in breast cancer. Furthermore, some recurrences, such as invasion of the brachial plexus, are intractable to treatment; recurrences on the chest wall present a terrible problem of management as well as make the patient absolutely miserable prior to death. The present knowledge, primarily of the combination of radiation and surgery in certain diseases, is not applied except to a very small segment of the cancer patient population. The spread of information and the increased use of effective methods should be encouraged.