Early breast cancer: part II. Management

Long-term follow-up of a randomised trial designed to determine the need for irradiation following conservative surgery for the treatment of invasive breast cancer

Four hundred consecutive patients aged under 70 years diagnosed with a clinical T1 or T2 breast cancer were randomised to receive post-operative radiotherapy (n = 208) or not (n = 192), and monitored to record all local recurrences, distant recurrences and deaths for up to 20 years (median 13.7 years). All patients were treated by wide local excision and adjuvant therapy [estrogen receptor (ER) positive: tamoxifen; ER negative: CMF chemotherapy]. Kaplan-Meier and log-rank test methods were used to estimate and compare survival and recurrence. The 20-year Kaplan-Meier rates for local breast recurrence were 28.6% [95% confidence interval (CI) 19.6% to 37.6%] for radiotherapy and 49.8% (95% CI 40.8% to 58.9%). There was no significant difference between the two groups with regard to disease-free or overall survival. The hazard ratio for death among women who received radiation, as compared with those that did not, was 0.91 (95% CI 0.64-1.28; P = 0.59). Therefore, post-operative radiotherapy produced a clear-cut reduction in locoregional recurrence 0.45 (0.31-0.64; P = 0.0001), but did not influence the incidence of distant metastases or time of death. However, of the 119 patients who had a local recurrence, 51 (42.8%) had a distant recurrence, whereas of the 281 without local recurrence only 59 (21%) ever had a distant recurrence. A Cox's regression analysis with local recurrence as a time-dependent variable showed a risk ratio of 5.28 (P < 0.0001). This strong relationship is dependent on the intensity of post-treatment follow-up and investigation.

Is less than mastectomy a safe option?

Studies of the curability of breast cancer are reviewed. Of patients presenting with early disease, who are treated by ablative surgery, with or without postoperative radiotherapy, the proportion cured is small, with estimates of that proportion ranging from 0-30%. This fact must seriously modify arguments that failure to carry out a particular form of local treatment jeopardizes an individual patient's chances of cure. Techniques now exist whereby the breast can be conserved with acceptable cosmetic results in up to 90% of patients and with a salvage mastectomy rate of 10-15% at 10 years. These techniques can safely be applied to patients with tumours up to 5 cm in diameter whether or not homolateral nodes are palpable. Both survival rates and local recurrence rates are equivalent to those obtained by more radical surgery. Data from two clinical trials and numerous uncontrolled studies are reviewed and support these conclusions. A rigid application of a policy of total mastectomy as recommended by the Consensus Development Conference cannot be justified by arguments that alternative treatment carries with it an increased risk of recurrence or death. Such arguments are not supported by the data available in the literature. Strict rules regarding tumour size or the palpability of axillary nodes, which make conservation a safe alternative to mastectomy, are equally illogical and are also not supported by the data available. True and valid consent by a patient to any procedure requires a fair discussion of alternatives. We believe that the evidence that less than mastectomy is a safe alternative to radical surgery is so strong every woman presenting with operable breast cancer is entitled to discuss this approach to her management.

Management and survival of female patients with "minimal" breast cancer: as observed in the long-term and short-term surveys of the American College of Surgeons

The American College of Surgeons' long-term breast cancer survey in 1978 included 16,894 pathologically confirmed carcinomas of the female breast, in situ or infiltrative, with negative or positive nodes. Of these, 1.9% were in situ carcinoma of any size, and 8.4% were minimal invasive carcinomas 1 cm or less in diameter. No significant difference was found between the survival of patients with in situ tumors of any size and minimal invasive tumors with negative axillary nodes measuring 1 cm or less in diameter. In patients with invasive tumors with negative axillary lymph nodes, no statistically significant difference was found in survival of patients with tumors of 0.5 cm or less, when compared either with survival of patients with tumors measuring 0.6-1.0 cm. Recurrence rates observed in those groups were not statistically significant. Among 157 patients with invasive tumors measuring 0.5 cm or less, 23.0% presented with axillary lymph node metastasis. Tumors measuring 0.6 to 1.0 cm showed 20.9% positive axillary nodes in 964 patients. Statistically significant differences in survival and recurrence rates were achieved only for invasive tumors smaller than 1 cm. Survival and recurrence rates were significantly better (P less than 0.001) in patients with minimal invasive cancer with negative axillary nodes (P less than 0.001) than rates of patients with invasive tumors larger than 1 cm and with negative lymph nodes. Similar statistical results were obtained for patients with positive axillary nodes only for invasive cancers smaller than 1 cm. However, survival and recurrence rates observed in invasive cancers of 1 cm or less with positive axillary nodes suggest that tumor size alone cannot be used as the only defining criterion for minimal invasive breast cancer. Only the status of axillary nodes may determine whether a small invasive tumor below 1 cm may be considered as minimal breast cancer.