Surgery for Invasive Breast Cancer
Adjuvant Chemotherapy and Breast-Conservation Therapy
In general, cytotoxic chemotherapy is felt to have a minimal impact upon local relapse rates in the breast. A notable exception, the NSABP-B13 trial of chemotherapy versus no adjuvant systemic therapy for node-negative patients, included many patients treated with BCT, and the incidence of local recurrence was significantly lower in the group receiving chemotherapy.
Trials are underway to further define the issue. Neoadjuvant chemotherapy has been shown to increase the proportion of patients suitable for BCT without any effect on overall survival.
Patient Selection Criteria for Breast-Conservation Therapy
The patient’s choice regarding BCT or mastectomy must be informed.
There are only two contraindications to BCT: inability to excise the local disease completely and inability to complete radiation therapy to the breast.
Patients considered poor candidates include patients in the first two trimesters of pregnancy, patients with widespread multifocal breast cancer and patients with cancer arising in an irradiated area. Patients with collagen vascular or autoimmune disease, such as scleroderma, respond poorly to radiation and should not undergo BCT.
Cosmetic concerns are a relative contraindication to BCT. If the tumor is large relative to the size of the breast, the result of conservation is likely to be poor, and so BCT may be contraindicated. The fundamental issue for the patient is the psychological benefit of breast preservation, compared with the requirement for radiation therapy and the subsequent risk of breast cancer recurrence.
Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
References
- Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiation therapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6-11.
This is the landmark report of the first randomized prospective trial of breast-conservation therapy. - Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.
This is the first report of the major North American trial of breast-conservation therapy from the NSABP. - Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This is a review of all aspects of breast-conservation therapy. - Fisher B, Costantino J, Redmond C et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993: 1581-6.
This is the major trial of conservative therapy for DCIS - Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.
This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease. - Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.
This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy. - Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.
This report gives a good idea of the range of complications after axillary dissection.