With early, non-invasive breast cancer, surgery to remove the cancer is usually the
treatment of choice. But what type of surgery? Should it be radical - removal of the
whole breast - or minimal, removal of the lump and conserving the breast? Randomised
trials have been criticised because with small breast cancers follow-up must be for a
long time to be sure that differences in recurrence locally or at distant sites are
not being missed. Two studies have now reported on 20-year follow-up, and both
confirm that lumpectomy plus irradiation gives similar results to radical mastectomy
[1,2].
Italian study [1]
Between 1973 and 1980, 701 women with breast cancers with a maximal diameter of 2 cm
or less (stage T1) and no palpable nodes and who were younger than 70 years were
recruited. They were randomised to radical mastectomy or breast-conserving surgery
with complete axial dissection and postoperative irradiation to the affected breast.
From 1976 all patients with positive axillary nodes were additionally given 12
monthly cycles of chemotherapy.
Patients were seen every three months for the first 10 years, and annually
thereafter. Annual visits included mammography.
Results
The average age of the women was 51 years, and the median follow up was 20 years.
Only three women were lost to follow up. In almost all women the primary cancer was
palpable. The two groups of women had similar baseline characteristics for menopausal
status, size and site of tumour and axillary node metastases.
The results are shown in Table 1. The only significant difference was in the rate of
local recurrence, at 2.3% for radical mastectomy and 8.6% for breast-conserving
surgery. There was no difference in rates of contralateral breast cancer, distant
metastases, other cancers, breast cancer deaths or all-cause mortality.
Table 1: Twenty-year results of Italian randomised trial of breast cancer
surgery
|
|
Radical mastectomy
|
Breast-conserving surgery
|
| Number |
349 |
352 |
Outcome [number, (%)]
|
| Local recurrence |
8 (2.3) |
30 (8.6) |
| Contralateral breast cancer |
34 (9.7) |
29 (8.3) |
| Distant metastases |
83 (24) |
82 (24) |
| Other primary cancers |
30 (8.6) |
31 (8.9) |
| All cause death |
152 (44) |
156 (44) |
| Breast cancer death |
86 (25) |
91 (26) |
US study [2]
Between 1976 and 1984 women with breast cancers with a maximal diameter of 4 cm
or less and with negative or positive axillary nodes were randomised to radical
mastectomy, lumpectomy, or lumpectomy plus breast irradiation.
Results
There were 1,851 women followed up for an average of 20 years. About 60% of women
were older than 50 years. The groups had similar baseline characteristics for
menopausal status, size and site of tumour and axillary node metastases.
The results are shown in Table 2. The only significant difference was in the
rate of local recurrence, at 2.7% for breast-conserving surgery with irradiation
but higher for radical mastectomy and lumpectomy alone. There was no difference
in rates of contralateral breast cancer, distant metastases, other cancers,
breast cancer deaths or all-cause mortality.
Table 2: Twenty-year results of US randomised trial of breast cancer
surgery
|
|
|
Radical mastectomy
|
Lumpectomy alone
|
Lumpectomy plus irradiation
|
| Number |
589 |
634 |
628 |
Outcome [number, (%)]
|
| Local recurrence |
60 (10) |
58 (8.8) |
17 (2.7) |
| Contralateral breast cancer |
50 (8.5) |
56 (8.8) |
59 (9.4) |
| Distant metastases |
132 (22) |
158 (25) |
163 (26) |
| Other primary cancers |
43 (7.3) |
32 (5.0) |
49 (7.8) |
| All cause death |
371 (63) |
408 (64) |
391 (62) |
The cumulative incidence of death from any cause in all 1,851 women was 54% at
20 years, and 40% died after a recurrence or diagnosis of cancer in the
contralateral breast.
Comment
Results were consistent, with the exception that the Italian study found lower
rates of local recurrence with mastectomy, albeit with few actual events.
Meta-analyses of trials in breast cancer have found no significant difference
between mastectomy and lumpectomy at 10 years.
The finding of these two trials of no important difference at 20 years provides
even more confidence that, where appropriate, lumpectomy plus irradiation is safe
and effective treatment for early breast cancer.
Remarkable in these trials is the high degree of follow up over 20 years, and
the consistency of the results. Together with other evidence that mastectomy does
not have any survival advantage over lumpectomy, the lack of superiority of
mastectomy over breast-conserving surgery is pretty much nailed down.
The question of which women with breast cancer should be offered which treatment
is eloquently addressed in an accompanying article [3]. The thrust of this is
that breast-conserving surgery is underused, at least in the USA.
References:
- U Veronesi et al. Twenty-year follow-up of a randomized study comparing
breast-conserving surgery with radical mastectomy for early breast cancer. New
England Journal of Medicine 2002 347: 1227-1232.
- B Fisher et al. Twenty-year follow-up of a randomized trial comparing total
mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of
invasive breast cancer. New England Journal of Medicine 2002 347:
1233-1241.
- M Morrow. Rational local therapy for breast cancer. New England Journal of
Medicine 2002 347: 1270-1271.
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