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

Preoperative or postoperative irradiation as adjunctive treatment with radical mastectomy in breast cancer

Results from the standpoint of survival rates and locoregional failures are compared in three series of patients having had a radical mastectomy for breast cancer: (1) radical mastectomy alone for the patients who had essentially outer quadrant lesions and a negative axilla; (2) postoperative irradiation when the axillary nodes were positive and/or the tumor was centrally located or in the inner quadrants; and (3) preoperative irradiation for patients with an outside biopsy presenting with a very disturbed breast with edema and ecchymosis, and in a small group of patients with a lesion of clinically borderline operability. The ten-year survival rates are identical in the three groups. In the radical mastectomy alone group, 14% of the patients had positive axillary nodes, in the preoperative irradiation group 30% (probably one half of the true incidence without preoperative irradiation), and in the postoperative group, 71%. This data is indicative that irradiation, either pre- or postoperatively, has survival benefits since there is direct relationship between the percentage of patients with positive axillary nodes and the survival rates. However, there is no evidence that preoperative irradiation is superior to postoperative irradiation.

Biopsy and definitive radiation therapy in stages I and II carcinoma of the female breast

One hundred-twenty patients with Stages I and II carcinoma of the female breast were treated by biopsy followed by definitive radiation therapy without mastectomy. The breast received 4500-5000 cGy (rad) using a 6 MV linear accelerator followed by a supplement to the area of the primary tumor of 2000 cGy (rad) using electrons in 99 patients (83%) and interstitial implantation in 21 patients (17%). Local recurrence was not recorded in the 43 patients with Stage I disease, while three of 77 patients (4%) with Stage II disease suffered a local recurrence. The actuarial five-year relapse-free survival was 91% and 60% in Stages I and II respectively. Cosmetic results were considered excellent by both physician and patient in the majority of cases. Axillary dissection was the recommended method of staging the axilla but was noted to be more morbid than axillary sampling. Electrons may be as effective as interstitial implantation as a means of supplementation following external beam therapy if specific guidelines are followed.

The role of the randomized clinical trial in the evaluation of new operations

Randomized trials that compare new operations with old ones or new regimens of invasive therapy with standard operations can make a substantial contribution to medical knowledge if the stipulations outlined in this article are followed. However, randomized trials that compare medical with surgical therapy have a number of additional problems and as a result rarely have a major impact on the practice of medicine.

Breast cancer: a 21 year experience with conservative surgery and radiation

Evidence is presented from a study of 680 patients followed over a period of 21 years that conservative treatment of breast cancer by local excision of the primary tumor followed by breast irradiation yields results equivalent to the traditional radical approach, with the added benefit of an excellent cosmetic result and improved quality of life. The relative survivals were 8.3% at 5 years and 71% at 10 years. There was no difference in survival when radiation was given. Breast irradiation significantly reduced relapse in the breast, but axillary irradiation did not influence relapse at this site. Relapse in the breast alone was not detrimental to survival if treated appropriately. Axillary relapse indicated a much poorer prognosis as might be expected.

Treatment of primary breast cancer without mastectomy. Review of the literature

During the 54-year period between 1927 and 1981, at least 4,290 patients with breast cancer treated with lumpectomy and/or radiotherapy as the primary therapeutic modality have been described. In all but two of the 24 reported studies, survival rates, even to 30 years, were similar to those of patients treated with variations of radical mastectomy, and the cosmetic result following treatment that preserved the affected breast was judged good to excellent by 81 to 85 percent of the patients so treated. The two exceptions were both in series of patients treated with doses of radiation known to be inadequate by current standards. We all have the responsibility of offering our patients the most effective treatment available with the fewest possible short-term and long-term side effects. This goal requires a constant, careful reevaluation of our treatments and results, as well as an open mind. According to available data, the combination of lumpectomy, axillary node dissection, external beam radiotherapy and iridium implant constitutes an acceptable alternative to mastectomy as treatment for primary cancer of the breast.

The management of breast carcinoma by primary radiotherapy at Mount Sinai Hospital from 1962--1979

Two-hundred eight patients with carcinoma of the breast were treated with megavoltage irradiation as the primary method of local management at Mount Sinai Hospital between 1962--1979. The effects of treatment volume, technique, and other parameters are discussed for the Stage I and II patients, together with the importance of tumor size and nodal status in control of local disease and distant metastases. In this series the cumulative probability of freedom from metastases is 93 +/- 5% when the irradiation is confined to the breast and axilla as compared with 72 +/- 9% when extended fields are used, with no difference in local control. Based on these results it was decided to confine irradiation to the breast and axilla alone in the majority of early stage cancer patients. Recommendations are made for radiation techniques and dosages to optimize control of the disease, minimize complications, and facilitate systemic therapy in patients with positive nodes.

Trattamento Radiante Elettivo del Carcinoma Mammario

From March 1972 to November 1979 a total of 157 patients with stage I to III primary breast cancers have been irradiated after segmental resection (12 cases), tilectomy (89 cases) or biopsy (56 cases). Complete local control was achieved in all Stage I lesions, in 97 % Stage II lesions and in 68 % Stage III lesions. Non recurrence has been observed in patients previously operated by segmental resections, while local failures occurred in 6/89 and in 16/56 patients operated by tilectomy or biopsy, respectively. Of the 28 Stage I patients, 24 (86 %) are alive, one with distant metastases. Four patients of this group are dead, 2 of intercurrent disease and 2 of breast cancer. Of the 61 (Stage II) patients, 38 (62 %) are alive, 5 of these with distant metastases. Twenty-three patients are dead, 15 with active disease, and 8 suffered intercurrent death. Of the 68 Stage III patients, 21 (31 %) are alive, 6 of these with distant metastases. Fourty-seven patients are dead, 43 of breast cancer and 4 of intercurrent disease. The high probability of initial subclinical deposits is evidenced by the fact that 49 of the 68 patients in this group developed distant metastases. The patients with T1 lesions appear to comprise the most favourable group with a relapse free survival at five years of 76 %. The 5 years relapse free survival was 62 % for T2 lesions and 25 % for T3 and T4 lesions. N0 status does not confer the same favourable prognosis as T1 status. N+ status, however, resulted in a definitly negative prognostic factor. Cosmetic results after our treatment approach appear to be extremely good. A marked difference between the irradiated and controlateral breast occurred only in 10 of the 125 patients after a minium of 2 years observation.

Findings from NSABP Protocol No. B-04: comparison of radical mastectomy with alternative treatments. II. The clinical and biologic significance of medial-central breast cancers

Findings from 1665 women with primary breast cancer, treated at 34 NSABP institutions in Canada and the United States, have failed to demonstrate that patients with medial-central tumors had a greater probability of developing distant metastases or dying than did those with lateral tumors despite the greater incidence of internal mammary (IM) node involvement when tumors are medial-central in location. A comparison of patients with similar clinical nodal status and tumor location who were treated either by radical mastectomy (RM) or by total mastectomy plus radiation therapy (TM + RT) failed to indicate that radiation of IM nodes reduced the probability of distant treatment failure (TF) or mortality. When findings from patients having equivalent clinical nodal status and tumor location treated by TM alone or TM + RT were compared, it was found that the addition of RT failed to alter the probability of the occurrence of a distant TF or of death. This was despite the fact that in the nonradiated group two putative sources of further tumor spread, i.e., positive axillary and IM nodes, were left unremoved and untreated. The findings provide further insight into the biologic significance of the positive lymph node and confirm our prior contention that positive regional lymph nodes are indicators of a host-tumor relationship which permits the development of metastases and that they are not important investigators of distant disease.

Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast

From 1973 to 1980, we carried out a controlled study at the National Cancer Institute in Milan to consider the value of a conservative procedure in patients with breast cancer of small size. We randomized 701 patients with breast cancer measuring less than 2 cm in diameter and with no palpable axillary lymph nodes to Halsted radical mastectomy or to "quadrantectomy" with axillary dissection and radiotherapy to the ipsilateral residual breast tissue. We treated 349 patients with Halsted mastectomy and 352 with quadrantectomy. The two groups were comparable in age distribution, size and site of primary tumor, menopausal status, and frequency of axillary metastases. There were three local recurrences in the Halsted group and one in the quadrantectomy group. Actuarial curves showed no difference between the two groups in disease-free or overall survival. From these results, mastectomy appears to involve unnecessary mutilation in patients with breast cancer of less than 2 cm and no palpable axillary nodes.

Breast self-examination, relationship to stage of breast cancer at diagnosis

Data from 996 newly diagnosed breast cancer patients indicated a highly significant association (P less than 0.001) between periodic breast self-examination (BSE) and pathologic stage of disease. Among women reporting periodic BSE, only small differences were noted between those who practiced monthly and those who practiced several times annually. Average maximum tumor diameter and frequency of tumors 4 cm or large were significantly greater (P less than 0.01) among women who rarely or never practiced BSE. The relationship between the periodic practice of BSE and the diagnosis of breast cancer before nodal involvement was present even after controlling for a wide variety of variables. The regular practice of BSE was associated with a one-third reduction in the likelihood of diagnosis of disease with positive nodes. This difference translated to a 10% decline in five-year mortality for whites and a 17% decline for nonwhites.

The surgeon's role in primary breast cancer

During the 1960s, it was suggested that, at least in clinical stage I disease, simple mastectomy or even wide excision, plus radiotherapy to the breast and gland fields resulted in the same distant recurrence rate and survival as the orthodox radical operation. It was thought that local control of the disease was not important in terms of ultimate prognosis and it was felt that minimal surgery incurred no penalty. It was forecast that breast cancer would soon be treated by radiotherapy alone, possibly even without removal of the tumour. Four developments have materially affected the situation. 1. It has been shown that assays of hormone receptors should be carried out on all primary tumours. 2. In clinical stage II disease, it has been demonstrated that restricted surgery results in a penalty in terms of distant recurrence and survival. 3. It is now realised that the number of involved axillary lymph nodes must be known to evaluate future prognosis. 4. Adjuvant chemo or endocrine therapy have proved to be effective in treating patients with heavy axillary node involvement. These developments mean that the effective treatment of early breast cancer must entail removal of the tumour, achieve local control of disease and include axillary node dissection. Currently, only the modified radical mastectomy effectively equates with these three aims. Nevertheless, it is possible that tumour excision, irradiation to the tumour bed and breast, and axillary node dissection would achieve the same object whilst conserving the breast.

A commentary on the role of the surgeon in primary breast cancer

The function of the surgeon remains the same relative to the management of primary breast cancer. What has changed is our perception of the biology of the disease and our understanding of data evaluation and analysis. This presentation provides an overview of some of the more important findings which have altered our understanding of breast cancer and which have led to a reassessment of the basis for cancer surgery. It also emphasizes why controlled clinical trials are necessary for obtaining credible data. To most succinctly summarize the author's position regarding a number of critical controversies related to primary breast cancer surgery, answers are presented to ten of the questions most frequently posed by surgeons regarding surgical therapy.

The risk of chemotherapy

Human survival curves may be classified according to the magnitudes of their hazard rate derivatives into three elementary shapes or groups: Aging (lambda' (t) greater than 0), random death (lambda' (t) = 0) and regeneration (lambda' (t) less than 0). Each observed survival curve is assumed to be composed of one or more elementary shapes. The aging pattern is observed in population cohorts from the age of 15 years and onward. It underlies survival curves of experimental animal treated by whole body irradiation which is assumed to act via the nervous system inducing generalized hypoplasia by impeding its trophic function. The whole process is manifested by an increasing lambda (t). Regeneration, is associated with the mobilization of reserves to withstand a noxious perturbation. The regeneration pattern is observed in patients surviving myocardial infarction, or recovering from surgical intervention. It is shared also by all survival curves of the 4th report on end results of cancer, and is assumed to reflect the beneficial role of neoplasia. While the hazard rate lambda (t) reflects mortality, its derivative lambda' (t) is viewed here as a measure of morbidity, so that cancer treatment effectiveness has to be assessed by its influence on both. A beneficial treatment ought to reduce them and vice versa. Most survival curves published in the modern cancer literature indicate an increasing morbidity accompanying treatment manifested by a positive hazard rate derivative (lambda' (t) greater than 0).

Inefficacy of internal mammary nodes dissection in breast cancer surgery

From January 1964 to January 1968, 737 patients with breast cancer were randomized at the Cancer Institute in Milan to undergo either Halsted mastectomy or Halsted mastectomy with internal mammary node dissection; 716 were considered evaluable. The series was part of an international cooperative study. The two groups of patients were comparable in age, menopausal status, quadrant distribution, and frequency of axillary metastases. No patients received postoperative radiotherapy or adjuvant treatments. At ten years, no difference was found in either in the length of disease-free or overall survival in the two series. The overall survival was 60.7% in patients treated with Halsted mastectomy and 57.0% in patients treated with Halsted mastectomy plus internal mammary dissection. In no subgroups was a statistically significant difference found. In the series treated by extended mastectomy, the incidence of internal mammary metastases was 20.5% (24.6% in cases with tumor in medial or central quadrants and 17.7% in cases with tumor in lateral quadrants). The follow-up of the patients treated by Halsted mastectomy showed that only 15 had a parasternal recurrence; the expected number was 75. In nine patients, parasternal recurrences were the first site of relapse of the disease. All of them were treated with radiotherapy, and in four a complete control was obtained.

Stage III carcinoma of the breast. A detailed analysis

A ten-year study of Stage III breast carcinoma has been reviewed in detail. The single most dominant variable was axillary nodal involvement. Four hundred and thirty patients had nodal metastases, 58 patients did not. Four hundred and thirty patients with axillary nodal involvement had fiveand ten-year recurrence rates of 68 and 77%, while the survival rates were 41 and 21%, respectively. Life span was influenced by extent of nodal disease, being best for those with micrometastases only, and worse for those with four or more positive nodes. Skin edema, infiltration, or ulceration in the positive node group were grave signs. Muscle invasion or node matting, however, did not appear to influence length of life. Postoperative prophylactic therapy did not appear to affect survival rates. Radiation therapy alone did not influence either local recurrence or survival rates. Not enough time has elapsed to evaluate the results of postoperative chemotherapy. Patients who underwent oophorectomy and radiation therapy appeared to do better, but the number of patients was small. Of the 58 patients without nodal invasion, 82% were alive at five years and 75% were alive at 10 years. Grave signs did not influence the survival rate in this group. While the majority of patients with Stage III carcinoma had unfavorable variables, there were some patients who demonstrated a low recurrence rate and a long survival time. Aggressive treatment should be designed to save those patients who can be helped and to improve those patients whose life expectancy is limited. There is no place for timid initial treatment whether by operation or by irradiation. It must be given with intent to cure even though palliation is most often attained.

The contribution of recent NSABP clinical trials of primary breast cancer therapy to an understanding of tumor biology--an overview of findings

Disagreement about local-regional management of primary breast cancer is related to differences in perception of the biology of the disease. Other factors are secondary and obscure the reality that all treatment must be related to biological considerations; otherwise, the basis for therapy is relegated to speculation and to personal experience. As a result of extensive laboratory and clinical studies during the past two decades, there has arisen an altered concept of cancer biology. The National Surgical Adjuvant Project for Breast and Bowel Cancers (NSABP) has made a major contribution to the change through findings from a series of prospective randomized clinical trials. That group of American and Canadian investigators has implemented a series of trials aimed at answering biological as well as clinical questions. Those studies have not only been concerned with defining proper local-regional treatment but have also pointed out the need for, and value of, systemic therapy when used in conjunction with operation. This report will provide an overview of past and present NSABP contributions and will consider those findings in relation to observations from other clinical trials of pertinence. It will emphasize that controversies concerning breast cancer management are related to biological issues that cannot be resolved by "populism" or appeals to emotion.

Cancer metastasis: a product of tumor-host interactions

Metastasis continues to be the most devastating event for the patient with an established primary cancer. The most significant therapeutic problems are: (1) treatment of patients with established macrometastases, (2) identification of patients who have micrometastases and (3) the development of adequate adjunctive therapies for micrometastases. It is hoped that our evolving understanding of the biology of experimental metastasis and the high level of premium quality laboratory research ongoing in this area will result in further resolution of this clinical problem or, at least, a better understanding of this most extreme expression of the malignant phenotype.

Early breast cancer: part I: surgical pathology and preoperative assessment

The management of early breast cancer is showing a growing tendency to move away from radical surgery back towards conservative surgery and systemic adjuvant therapy. This paper and the one that follows review the data that underly this trend and consider the clinical and biological principles that are presently used to make a decision regarding the optimal primary treatment for breast cancer. The conclusion is reached that conservatism is based on a false understanding of the disease and on false conclusions drawn from premature analysis of data from clinical trials.

Optimal management can be determined by appropriate preparative investigation. Breast cancer patients can be divided into three groups: early cases, with a good prognosis, late, incurable cases and an intermediate group. Radical therapy by surgery or surgery combined with radiotherapy gives better results than a conservative approach in the early and intermediate groups. The intermediate group should be seen as having a poor, but not necessarily hopeless prognosis. These cases may benefit particularly from adjuvant chemotherapy, but this should not be used as an excuse to deny the patient adequate local measures, which alone (at present) offer hope of cure. The problem posed by the third group should be seen as one of optimal palliation.

Adjuvant systemic therapy raises hope of improving results, but no patient with breast cancer has yet been cured by chemotherapy or the application of immunological principles. Future improvements are most likely to derive from optimal use of each modality, and not at the expense of the most effective method at present available–radical surgery. The many remaining questions regarding management can best be answered by careful, controlled clinical studies, and every effort should be made to include patients with a poor prognosis in appropriate clinical trials.