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

What drove changes in the use of breast conserving surgery since the early 1980s? The role of the clinical trial, celebrity action and an NIH consensus statement

BACKGROUND

Three important events in the history of breast cancer treatment occurred between 1983 and 1995: a large clinical trial, first lady Nancy Reagan's choice of mastectomy and the publishing of an NIH consensus statement.

OBJECTIVE

To assess the effects of these events on use of breast conserving surgery (BCS).

RESEARCH DESIGN

Data from the cohort study of the surveillance, epidemiology and end results (SEER) Program from 1983 to 1995 were divided into four periods: Baseline, Trial, Celebrity, and Consensus.

SUBJECTS

Of the women, 169,466 diagnosed with early stage breast cancer in nine SEER areas.

MEASURES

Monthly percentages of BCS.

RESULTS

A linear regression model generated a separate intercept and slope term for four time periods, adjusting for demographic characteristics of breast cancer patients. For the Baseline, Celebrity and Consensus Periods, slopes indicated an increasing use of BCS which varied between 0.24% and 0.28% per month. Slopes for these three periods were not statistically different (p = 0.120). In contrast, there was no change in use of BCS during the trial period (p = 0.247). We tested the magnitude of discontinuity between periods. At the beginning of the trial, celebrity and consensus periods, there were increases in BCS of 5.54% (p < 0.001), -3.55% (p < 0.001), and 2.37% (p < 0.001), respectively.

CONCLUSIONS

The use of BCS was substantially affected by the reports of a clinical trial of BCS and by celebrity action. These effects were abrupt but transient. The NIH consensus statement stimulated a small change in use of BCS and may be an important intervention for maintaining the increasing trend in use of BCS since the 1990s.

Tumorectomy and radiotherapy in early breast cancer: a report on 392 patients

This study includes 392 patients (231 Stage I and 161 Stage II) treated by tumorectomy followed by radiotherapy. The overall actuarial survival for all the patients is 86.5% at 5 years and 78% at 10 years. The 5-year NED survival is 70.2%. The survival rates are depending on the loco-regional extension: Stage I: 92% survival at 5 years and 84% at 10 years; Stage II: 82% survival at 5 years and 75% at 10 years. The percentage of local recurrences were 13% for all stages (10.6% for Stage I, 16% for Stage II), of lymph node recurrences: 1.5% for all stages, 1.3% for Stage I, 2% for Stage II, of distant metastases: 11.2% for all stages, 8% for Stage I and 16% for Stage II. The loco-regional control rates were analyzed according to the TNM classification and discussed and compared to several literature data. The breast preservation rates were at 5 years 85% for Stage I and 80.9% for Stage II. Cosmetic results are judged as good in 80% by doctors and in 90% by patients themselves with very low complication rates.

Conservative treatment for breast cancer. Complications requiring reconstructive surgery

Women who select conservative treatment for carcinoma of the breast (tumor excision followed by supervoltage radiation therapy) place a premium on breast preservation and aesthetics. When local control fails and they require a mastectomy, or when the aesthetic appearance is unacceptable, they may request breast reconstruction. The goal of this study is to evaluate a series of 10 patients who required reconstructive breast surgery after complications of conservative treatment. Patient classification: I. Breast or chest wall necrosis (3). II. Breast fibrosis and gross asymmetry (3). III. Local recurrence of breast cancer (5). IV. Positive margins after the initial lumpectomy (1). The mean age was 34 years. Radiation dosage average was 5252 rads with two patients receiving iridium-192 implant boosts. The reconstructive management was complex and usually required a major musculocutaneous flap because of the radiation effects.

Illness-related and treatment-related factors in psychological adjustment to breast cancer

Seventy-eight breast cancer outpatients were interviewed and their medical records were reviewed to document illness-related and treatment-related factors associated with psychosocial adjustment. Poor prognosis and more radical surgery both independently predicted poor psychological adjustment. The effect of type of surgery appeared to be mediated by the patient's sense of disfigurement and by changes in the sexual and affectional patterns in the marriage, rather than by prognosis or disability. Degree of dysfunction and whether or not the patient had radiation therapy or chemotherapy had no independent effects on psychological adjustment. Results point to the problematic psychosocial outcomes associated with mastectomy and, more generally, to the illness- and treatment-related factors that may place a breast cancer patient at risk for psychosocial adjustment problems.

Leishmania braziliensis braziliensis infection of the nipple

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Radiation-induced changes in the breast

Thirty-six postirradiation breast tissue specimens from 30 patients with breast cancer treated by primary radiation therapy were evaluated to define the effects of therapeutic doses of ionizing radiation on the residual non-neoplastic breast tissue. Breast tissue was sampled an average of 30.4 months after completion of therapy because of the development of new clinically or mammographically detectable abnormalities within the treated breasts. The average radiation dose was 6,399 rad to the primary tumor area and 4,778 rad to the remainder of the breast. Breast tissue sections from 35 nonirradiated patients served as control specimens. The most characteristic radiation effects consisted of atypical epithelial cells in the terminal duct lobular unit ( TDLU ) associated with lobular sclerosis and atrophy. These changes were present in all of the irradiated patients but varied in severity and extent among patients and within individual patients. This variation was not related to the presence or absence of carcinoma elsewhere in the specimen, radiation dose, patient age, time to postirradiation tissue sampling, or use of adjuvant chemotherapy. Epithelial atypia in larger ducts, stromal changes, and vascular changes were less frequent but were always accompanied by prominent TDLU changes. Radiation effects could usually be clearly distinguished from carcinoma involving the TDLU by the absence of both cellular proliferation and distention of the involved TDLU and by the preservation of cellular polarity and cohesion in areas of presumed radiation-induced injury. Familiarity with these changes is of considerable practical importance in that they must be distinguished from new or recurrent neoplasms.

Pathobiology of breast cancer--treatment implications

In most patients (approximately 85%), breast cancer at the time of diagnosis is already a systemic disease. Multicentricity (20-40%) and synchronous (5-10%) and metachronous (15-30%) bilaterality are indicative of etiologically similar noxae. Ductal and lobular carcinoma in situ become invasive in approximately 50% of patients. Whereas ductal carcinoma in situ is mainly diagnosed clinically (lumpiness, tissue irregularity), lobular carcinoma in situ, a small, nonpalpable lesion, is usually discovered accidentally following biopsy for fibrocystic disease and/or suspicious mammography. Treatment of in situ and minimal (small invasive) breast cancer (less than or equal to 5 mm in diameter) is controversial, ranging from observation (lobular carcinoma in situ) over segmental excision to simple or radical mastectomy with or without lymphadenectomy and contralateral "mirror-image" biopsies. Long-term survival rates (90-95%) appear similar for patients with treated or untreated lobular carcinoma in situ. Patients with minimal breast cancer have as good a prognosis as those with ductal carcinoma in situ (long-term survival, 80-90%). Presently, a trend from radical to conservative surgery (lumpectomy, segmentectomy) is observed. Especially for in situ carcinoma, modified radical or even simple mastectomy may be considered overtreatment. For invasive carcinomas, lumpectomy and radiotherapy provide as good a chance of survival as radical mastectomy. Such equal survival indicates that although in 25% to 45% of patients with invasive carcinoma multifocal disease (in situ and invasive carcinoma) is left behind, subsequent radiotherapy is effective. Accordingly, patients with carcinoma in situ may be spared mutilating surgery in favor of radiotherapy. Because many patients at extraordinarily high risk of breast cancer cannot accept prophylactic mastectomy, thorough follow-up by clinical examination, mammography, sonography and biopsy is essential.

Pathologic predictors of early local recurrence in Stage I and II breast cancer treated by primary radiation therapy

Thirty-four gross and histologic features of the primary tumor in 231 cases of clinical Stage I and II invasive breast cancer were reviewed in an attempt to identify features which might correlate with an increased risk of local recurrence within the breast following biopsy and primary radiation therapy. Local recurrence risk at 5 years was calculated for each feature studied. While results are reported in terms of 5-year actuarial local recurrence risk, not all patients were followed for 5 years (median follow-up period, 44 months). Patients with cases in which the biopsy was less than excisional had a considerably greater actuarial risk of local recurrence at 5 years than those in which the biopsy was excisional (36% versus 8%; P = 0.0005). Among 154 infiltrating ductal carcinomas treated by excisional biopsy prior to radiotherapy, histologic features associated with a significantly increased local recurrence risk at 5 years were the combination of extensive intraductal involvement by carcinoma and high nuclear grade and/or high mitotic index. Twenty-seven tumors demonstrated this constellation of features, and there was a 5-year actuarial local recurrence risk of 39% among this group. The local recurrence risk for the remainder of the population was only 4% (P less than 0.0001). Thus, through pathologic examination of the primary, the authors identified a subgroup of patients with a considerably increased risk of local recurrence following biopsy and primary radiotherapy.