Limited surgical excision as the basis of a comprehensive therapy for cancer of the breast

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.

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)

Cosmetic results following primary radiation therapy for early breast cancer

In order to assess the cosmetic results of treatment, the results in 239 patients with early breast cancer treated by primary radiation treatment without adjuvant chemotherapy were reviewed. Four patients had bilateral cancers, making a total of 243 breasts available for analysis. Follow-up ranged from 24 to 78 months with a median of 33 months. The parameters measured were breast edema, retraction, telangiectasia, arm edema, and the overall cosmetic appearance. The cosmetic results declined over the first 3 years after treatment, but then stabilized. At 5 years, the overall cosmetic results were judged by physicians as excellent in 77%, good in 9%, fair in 9%, and poor in 5%. A fair or poor cosmetic result was highly correlated with the development of moderate or severe breast retraction. Telangiectasia was uncommonly the only cause of a fair or poor cosmetic result. Breast and arm edema were rarely noted to be significant, but were more common in patients who underwent axillary dissection. In 210 cases, a supplementary boost dose of radiation was delivered to the primary tumor area, and in 33 cases a boost was not used. This boost consisted of an interstitial iridium-192 implant in 204 cases and either high-energy photons or electrons in the remainder. At 4 years, no patient treated without a boost had a fair or poor result compared with 22% who received a boost (P = 0.13). The conclusion is that, in general, primary radiation treatment provides highly satisfactory cosmetic results for patients with early 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.

The effect of adjuvant chemotherapy on the cosmetic results after primary radiation treatment for early stage breast cancer

Breast cancer patients treated by primary radiation therapy who have positive axillary lymph nodes now typically receive adjuvant chemotherapy. In order to evaluate the effect of adjuvant chemotherapy on the response of the breast to radiation treatment, we compared the cosmetic results of 49 patients treated with adjuvant chemotherapy and 206 patients not treated with adjuvant chemotherapy. A variety of chemotherapy regimens were employed, most commonly a combination of cyclophosphamide, methotrexate and 5-fluorouracil (CMF). The median follow-up time for all patients was 33 months. Cosmetic results were scored by the physician at each follow-up evaluation as excellent, good, and fair or poor, depending on the presence and extent of radiation-related changes in the treated breast. Patients who received adjuvant chemotherapy were less likely to have an excellent overall cosmetic result than patients who did not receive adjuvant chemotherapy. At 24 months 24% of these patients had an excellent cosmetic result compared with 64% of patients who did not receive adjuvant chemotherapy (p = 0.0002). This difference was due primarily to a shift in chemotherapy-treated patients from an excellent to a good overall cosmetic result. Breast retraction was noted to be the most frequent determinant of a fair or poor cosmetic result and was more common in patients treated with adjuvant chemotherapy. At 24 months, 62% of these patients had evidence of breast retraction compared with 44% of patients who did not receive adjuvant chemotherapy (p = 0.06). We conclude from this preliminary analysis that adjuvant chemotherapy modifies the response of the breast to radiation, most notably by increasing the development of retraction.

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.

Primary radiation therapy for early breast cancer

Primary radiation therapy for early breast cancer is a combination of limited breast surgery for the removal of gross disease, and moderate doses of radiation for the control of residual subclinical disease. The results from retrospective studies using primary radiation therapy indicate that high levels of local tumor control with good cosmetic results can be achieved. Preliminary results from a prospective randomized clinical trial indicate that radical mastectomy and primary radiation therapy result in equivalent survival rates. Primary radiation therapy is a reasonable alternative to mastectomy when adequate surgical and radiotherapeutic expertise is available to deliver this treatment.

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.

Radiation therapy of early carcinoma of the breast without mastectomy

The results of the treatment of 176 patients with early breast cancer, using radiation therapy without mastectomy are reported. The likelihood of local recurrence was 5% for Stage I patients and 7% for Stage II patients. Local control was significantly greater in those patients receiving and iridium implant (1/73 vs. 10/111, P less than .05). The cumulative survival probability at five years is 96% for Stage I and 68% for Stage II. Local control with good cosmetic results is greatly influenced by surgical and radiotherapeutic technique. Gross tumor resection with careful reapproximation of the breast tissue and well-placed incisions facilitates the radiation therapy. Homogeneous external beam radiation to the breast and draining lymph nodes (4500--5000 rads) and supplemental local radiation to the sites of the primary lesion (in this series using interstitial implantation) are recommended.

Changing trends in breast carcinoma

In view of the more open medical and public discussion of breast cancer, and considering the general dissatisfaction with radical forms of surgery and radiotherapy, we examined computer records of 1,014 patients with carcinoma documented by the Tasmanian Breast Survey between 1956 and 1976. In the two epochs, 1956 to 1966 and 1967 to 1976, there was a 14% increase in the proportion of patients presenting with Stage I carcinoma, and a 9% decrease in the proportion of patients with Stage II (P = 0.0075) but there was no change in the proportion of patients with Stages III and IV. The utilization of radical mastectomy decreased markedly, irrespective of stage (P = 0.0000), as did the utilization of radiotherapy (P = 0.0000). The mean age at presentation did not change significantly.