Partial mastectomy alone in early breast cancer

Breast cancer: the role of radiation therapy after treatment by conservative surgery

The role of conservative surgery (CS) as definitive treatment of invasive breast cancer has not been established. Previous studies have demonstrated high rates of local tumour recurrence if CS is not followed by radiotherapy (RT). At present, it is impossible to identify subsets of patients who may be at acceptably low risk of recurrence after CS. The treatment of breast cancer by CS alone remains an important research question as this may avoid over-treatment by radiation for some patients. In Australia, a trial has been proposed by the ANZ Breast Cancer Trials Group, comparing CS alone to CS+RT. This paper reviews all available data on CS alone in order to stimulate debate as to the appropriateness of the trial and its end-points. Given that all prospective randomized trials have failed to show a survival disadvantage for CS alone it is essential to consider the value of all outcomes after CS or CS+RT. The conventional end-points proposed in the Australian study (mastectomy rate, disease-free survival (DFS) and overall survival (OS)) are selective. Without the addition of quality of life measures, the utilities of the strategies addressed in the trial cannot be evaluated. Data are presented on the desirability (utility) of the alternative approaches of CS or CS+RT based on data obtained from a questionnaire completed by Westmead Hospital staff. This preliminary study indicates that the majority of respondents to the questionnaire perceived that the strategy of CS+RT to have a higher utility than the strategy of CS alone.

Patterns of breast relapse after local excision +/- radiotherapy for early stage breast cancer

One hundred patients with breast recurrence have been identified from patients at the Royal Marsden Hospital, treated by local excision +/- radiotherapy for early stage primary invasive breast cancer between 1961 and 1985. The mean follow-up was 58 months (range 1 month - 19 years). In 74/100 patients, breast recurrence occurred within the breast parenchyma, was not associated with systemic relapse and carried a relatively good prognosis with a median survival of 77 months from the time of breast relapse. In 67 patients with parenchymal relapse in whom the site of relapse could be reliably compared with that of the original tumour, 60 (90%) patients developed recurrent tumours at or close to the primary site. In 24/100 patients, breast recurrence occurred in the overlying skin and in only two of these patients (2% of total) did recurrence actually occur within the scar tissue. Skin relapse was associated with systemic relapse and carried a relatively poor prognosis with a median survival of 36 months from the time of recurrence. The pattern of breast relapse was similar in irradiated and unirradiated patients. Skin relapse appears to be a manifestation of metastatic disease while parenchymal relapse may represent regrowth of primary tumour. This pattern of breast relapse questions the requirement for radiotherapy to the whole breast after local excision for early stage breast cancer.

Low-risk breast cancer patients treated by mastectomy and lower axillary dissection. The present status of the Danish Breast Cancer Cooperative Group Trial 77-A

From 1977 to 1982 a total of 2,935 women with breast cancer fulfilled the criteria for inclusion in the low-risk protocol of the Danish Breast Cancer Cooperative Group, DBCG 77-A. The operation performed was a total mastectomy with axillary dissection slightly modified according to Cady. Postoperatively the patients were examined clinically and by chest radiography with intervals for ten years or until recurrence. With a median observation time of seven years loco-regional recurrence appeared in 409 patients (13.9%): chest wall 9.3%, axilla 3.7%. Half of the recurrences were diagnosed within two years postoperatively. Metastases appeared in 396 patients (13.5%), mainly in bones and lungs; 96 patients (23.5%) with loco-regional recurrence and 174 (43.9%) with distant metastases died from breast cancer during the observation time. Life-table analyses of recurrence-free survival (61.7%) and survival (75.4%) are presented. The results of the treatment are in accordance with reports in the literature, but a straightforward comparison is impossible on account of a huge variation in surgical and postsurgical treatment. Finally, the surgical technique in the participating departments in this nation-wide study was evaluated. A high grade of uniformity with respect to loco-regional recurrences was found.

A clinical and histopathologic analysis of the results of conservation surgery and radiation therapy in stage I and II breast carcinoma

One hundred eighty women with clinical Stage I or II operable breast carcinoma were treated by radiotherapy following local tumor excision at Yale-New Haven Hospital through 1980. With a median follow-up time of 6.9 years, the actuarial 5-year overall and disease-free survival rates were 82% and 78%, respectively. The 5-year actuarial breast-recurrence-free survival rate was 92%. Several clinical-histopathologic features and treatment parameters were assessed for their significance as predictors of local breast failure or distant relapse. Cox lifetable regression analysis showed that patients with clinical Stage II carcinomas had significantly worse overall and relapse-free survival rates, but clinical stage alone had no effect on the rate of breast recurrence. Furthermore, a decrease in overall and disease-free survival was evident when necrosis was present in the tumor or when patients had an infiltrating lobular carcinoma. Breast recurrence-free survival was also influenced adversely by the presence of these two tumor features, especially when either tumor necrosis or infiltrating lobular carcinoma was found in conjunction with clinical Stage II lesions. Other histologic features such as grade, vascular invasion, perineural invasion, or the presence of an intraductal component of carcinoma did not affect outcome, nor did the treatment techniques employed appear to have a differential effect.