Local Therapy

Local treatment refers to treatment directed at the breast and regional lymph nodes. Local treatment alone can be curative in the majority of patients with stage I breast cancer and a substantial proportion of women with stage II and III disease.

Table 33.6 presents breast cancer staging by the American Joint Committee on Cancer.

The two principal options for local treatment of early-stage breast cancer are mastectomy and breast-conserving surgery combined with breast irradiation. With either option, assessment of lymph node involvement is usually performed, either by full axillary node dissection or a sentinel lymph node biopsy.

Several large randomized studies have compared mastectomy to breast-conserving surgery followed by radiation therapy. These studies have revealed no difference in distant disease-free survival or overall survival between women who had a mastectomy compared to those who received breast- conserving therapy. Based on these studies, the 1990 National Institutes of Health Consensus Development Conference on the Treatment of Early-Stage Breast Cancer concluded that, when possible, breast-conserving surgery combined with axillary lymph node dissection and postoperative radiation therapy is the preferred treatment for patients with early-stage breast cancer because it provides equivalent survival rates while preserving the breast. No change was made in this recommendation at the 2000 Consensus Conference. Although the four trials referenced above enrolled a total of 3947 patients, few of these women were over age 65 and none were over age 70. There are no compelling reasons, however, to believe that the relative efficacy of these two treatment strategies would be different in older compared to younger women.

In a retrospective study comparing women age 65 years and older to younger women, Merchant et al. found that breast-conserving surgery plus radiation results in local failure rates at 10 years of 4% versus 13%, disease-free survival of 72% for both groups, and overall survival of 82% and 84%, respectively, despite significantly less aggressive adjuvant therapy among the older women in this study. In general, elderly patients tolerate breast surgery well and even with general anesthesia have little documented postoperative morbidity and mortality. Furthermore, both breast-conserving surgery and mastectomy can be performed under local anesthesia with mortality rates approaching zero. Comorbid illness rather than age appears to be the main factor influencing surgical mobidity.

Studies of quality of life and functional outcomes following breast cancer surgery have revealed that perceptions of body image are better among women who have undergone breast-conserving surgery rather than mastectomy. There does not appear to be excess concern about recurrence in women who opt for conservative surgery in lieu of a mastectomy. Although these findings are largely from younger women, there is no reason to believe that this would be significantly different in older women. Investigators have shown that older women prefer and are more likely to choose breast conservation over mastectomy. Sandison et al. found that 34 of 38 women aged 70 or older who chose their own treatment had breast conservation and only 4 opted for mastectomy. Importantly, only 2 women in this study were unhappy with their choice of treatment at 12-month follow-up. Evaluating quality of life in a group of older women undergoing breast cancer surgery, Vinokur et al. found that more extensive surgery was associated with greater physical impairments following surgery.