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Breast conservation therapy: Are therapists too conservative?
Inr. .I Radiamn Oncology. BQl Phy.5 Vol. Printed in the U.S.A. All nghts reserved.
23. PD.
1083-1084
0360.3016192 $5.00 -t .oO Copyright (c’1992 Pergamon Press Ltd.
0 Editorial BREAST
CONSERVATION
THERAPY:
ARE THERAPISTS
MELVIN DEUTSCH, Department
TOO CONSERVATIVE?
M.D., F.A.C.R.
of Radiation Oncology, University of Pittsburgh Health Center, Presbyterian University Hospital, Pittsburgh, PA
noted wide geographical variation in the proportion of women treated with breast conservation therapy (7). Women in this group with metastasis to axillary lymph nodes were less likely to undergo breast conservation therapy than women without axillary node involvement. Whereas, 12.1% of the entire group of 36,982 women had breast conservation therapy, only 7.5% of those with involved axillary nodes had such therapy. As evidenced in the report by Sauer et al. (8), there seems to be a tendency to limit breast preservation therapy to those patients with the best prognosis both in terms of local control, disease-free, and overall survival. How reasonable is this approach to choosing therapy for breast cancer? For the patient with Stage I or II breast cancer who wishes to avoid mastectomy, the important question is not necessarily her likely ultimate outcome, but whether or not breast conservation therapy puts her at greater risk of developing distant metastasis or dying from breast cancer. There is no evidence that patients who have poor initial prognostic variables based on tumor size, histology, nuclear grade, hormone receptor status, and nodal status have a worse outcome if treated by lumpectomy and breast irradiation versus mastectomy. Results from the National Surgical Adjuvant Breast Project (NSABP) B-06 study show no difference in disease-free survival, distant diseasefree survival, or overall survival between patients treated by lumpectomy and breast irradiation versus mastectomy, regardless of nodal status or other prognostic variables (4, 5). NSABP data also show that lumpectomy and radiotherapy patients with positive nodes, all of whom received adjuvant chemotherapy, have a lower incidence of inbreast tumor recurrence compared to those who have uninvolved axillary nodes and who did not receive chemotherapy. Further analyses of NSABP studies B- 13 and B14 evaluating systemic therapy in Stage I patients and B- 15 and B- 16 evaluating systemic therapy in Stage II patients, also support the conclusion that systemic
Another large series, this one from Germany, published in this issue of the journal, provides evidence that lumpectomy and radiotherapy is equivalent to mastectomy for women with pathologically staged TlNO breast cancer with resection margins free of tumor (8). More surprising than the outcome which was predictable on the basis of previous randomized trials (4, 5, 9) is the apparent conservatism of the authors in selecting patients for breast preservation therapy. All patients eligible for inclusion in this trial had tumors pathologically determined to be 2 cm or less in size with uninvolved margins of resection and uninvolved lymph nodes. Thus, only patients with the most favorable outlook were considered for breast preservation therapy. In spite of the early results in this series showing comparability of breast preservation therapy with mastectomy, the authors do not even suggest that breast preservation therapy might be amenable to patients with more advanced cancers (T2 and/or N 1). Interestingly, all patients with medially located tumors, whether treated by mastectomy or lumpectomy and breast irradiation, also were treated with parasternal and supraclavicular regional irradiation. This report reflects the conservatism of many clinicians in choosing breast conservation therapy for patients with Stage I and II breast cancer. Recently reported data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute show a slight increase in the use of breast conservation therapy throughout the period 1983 to 1986 for the nine geographical areas surveyed (2). For white females with localized breast cancer, the proportion treated with breast conservation therapy in 1985-1986 varied from 19.6 to 4 1.5%. Women under age 65 and over 75 years were more likely to undergo breast conservation surgery. However, the older women were less likely than the younger to receive postoperative breast irradiation. Nattinger et al., in a review of Medicare women age 65-79 years treated by surgery for local or regional breast cancer in 1986, also
Accepted for publication
Reprint requests to: Department of Radiation Oncology, University of Pittsburgh Health Center, Presbyterian University Hospital, Pittsburgh, PA 152 13. 1083
1 June 1992.
1084
1. J. Radiation Oncology 0 Biology 0 Physics
therapy added to lumpectomy and breast irradiation further decreases the incidence of in-breast tumor recurrence compared to lumpectomy and breast irradiation alone (6). Fisher et al. report that patients who do develop an inbreast tumor recurrence after lumpectomy + breast irradiation are at greater risk for developing distant metastasis than those who do not (3). The earlier the occurrence of the in-breast tumor recurrence after initial treatment, the sooner is the distant metastasis likely to appear. How-
Volume 23, Number 5, 1992
ever, in spite of these findings the distant disease-free and
overall survival rates are not different from those treated initially with mastectomy. Thus, in-breast tumor recurrence is considered to be a marker predicting for distant metastasis rather than the cause of the distant metastasis. It is this author’s opinion that lumpectomy and breast irradiation is appropriate treatment for practically all patients with Stage I and II breast cancer (1). The main criteria for offering breast conservation therapy is the patient’s desire to keep her breast.
REFERENCE Deutsch, M. Radiotherapy after breast conservation surgery: How much is enough? Sem. Surg. Oncol. 8: 140-146;1992. Farrow, D. C.; Hunt, W. C.; Samet, J. M. Geographic variation in the treatment of localized breast cancer. N. Engl. J. Med. 326:1097-l 101;1992. Fisher, B.; Anderson, S.; Fisher, E. R.; Redmond, C.; Wickerham, D. L.; Wolmark, N.; Mamounas, E. P.; Deutsch, M.; Margolese, R. Significance of ipsilateral breast tumour recurrence after lumpectomy. Lancet 338:327-33 1; I99 1. Fisher, B.; Bauer, M.; Margolese, R.; Poisson, R.; Pilch, Y.; Redmond, C.; Fisher, E.; Wolmark, N.; Deutsch, M.; Montague, E.; Saffer, E.; Wickerham, L.; Lerner, H.; Glass, A.; Shibata, H.; Deckers, P.; Ketcham, A.; Oishi, R.; Russell, I. 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. 312:665-673;1985. 5. Fisher, B.; Redmond, C.; Poisson, R.; Margolese, R.; Wolmark, N.; Wickerham, L.; Fisher, E.; Deutsch, M.; Caplan. R.; Pilch, Y.; Glass, A.; Shibata, H.; Lerner, H.; Terz, J.: Sidorovich, L. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or
without irradiation in the treatment of breast cancer. N. Engl. J. Med. 320:822-828;1989. 6. Fisher, B.; Wickerham, D. L.; Deutsch, M.; Anderson, S.; Redmond, C.; Fisher, E. Breast tumor recurrence following lumpectomy with and without breast irradiation: An overview of recent NSABP findings. Sem. Surg. Oncol. 8: 153160;1992. Nattinger, A. B.; Gottlieb, M. S.; Veum, J.; Yahnke, D.; Goodwin, J. S. Geographic variation in the use of breastconservation treatment for breast cancer. N. Engl. J. Med. 326:1102-l 107;1992. Sauer, R.; Rauschecker, H. F.; Schumacher, M.; Gatzemeier, W.; Schmoor, C.; Dunst, J.; Seegenschmiedt, M. H.; Marx, D. Therapy of small breast cancer: A prospective study on 1036 patients with special emphasis on prognostic factors. Int. J. Radiat. Oncol. Biol. Phys. 23:907-914;1992. Veronesi, U.; Saccozzi, R.; Del Vecchio, M.; Banfi, A.; Clemente, C.; De Lena, M.; Gallus, G.; Greco, M.; Luini, A.; Marubini, E.; Muscolino, G.; Rilke, F.; Salvadori, B.; Zecchini, A.; Zucali, R. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N. Engl. J. Med. 305:6-l 1;1981.
23. PD.
1083-1084
0360.3016192 $5.00 -t .oO Copyright (c’1992 Pergamon Press Ltd.
0 Editorial BREAST
CONSERVATION
THERAPY:
ARE THERAPISTS
MELVIN DEUTSCH, Department
TOO CONSERVATIVE?
M.D., F.A.C.R.
of Radiation Oncology, University of Pittsburgh Health Center, Presbyterian University Hospital, Pittsburgh, PA
noted wide geographical variation in the proportion of women treated with breast conservation therapy (7). Women in this group with metastasis to axillary lymph nodes were less likely to undergo breast conservation therapy than women without axillary node involvement. Whereas, 12.1% of the entire group of 36,982 women had breast conservation therapy, only 7.5% of those with involved axillary nodes had such therapy. As evidenced in the report by Sauer et al. (8), there seems to be a tendency to limit breast preservation therapy to those patients with the best prognosis both in terms of local control, disease-free, and overall survival. How reasonable is this approach to choosing therapy for breast cancer? For the patient with Stage I or II breast cancer who wishes to avoid mastectomy, the important question is not necessarily her likely ultimate outcome, but whether or not breast conservation therapy puts her at greater risk of developing distant metastasis or dying from breast cancer. There is no evidence that patients who have poor initial prognostic variables based on tumor size, histology, nuclear grade, hormone receptor status, and nodal status have a worse outcome if treated by lumpectomy and breast irradiation versus mastectomy. Results from the National Surgical Adjuvant Breast Project (NSABP) B-06 study show no difference in disease-free survival, distant diseasefree survival, or overall survival between patients treated by lumpectomy and breast irradiation versus mastectomy, regardless of nodal status or other prognostic variables (4, 5). NSABP data also show that lumpectomy and radiotherapy patients with positive nodes, all of whom received adjuvant chemotherapy, have a lower incidence of inbreast tumor recurrence compared to those who have uninvolved axillary nodes and who did not receive chemotherapy. Further analyses of NSABP studies B- 13 and B14 evaluating systemic therapy in Stage I patients and B- 15 and B- 16 evaluating systemic therapy in Stage II patients, also support the conclusion that systemic
Another large series, this one from Germany, published in this issue of the journal, provides evidence that lumpectomy and radiotherapy is equivalent to mastectomy for women with pathologically staged TlNO breast cancer with resection margins free of tumor (8). More surprising than the outcome which was predictable on the basis of previous randomized trials (4, 5, 9) is the apparent conservatism of the authors in selecting patients for breast preservation therapy. All patients eligible for inclusion in this trial had tumors pathologically determined to be 2 cm or less in size with uninvolved margins of resection and uninvolved lymph nodes. Thus, only patients with the most favorable outlook were considered for breast preservation therapy. In spite of the early results in this series showing comparability of breast preservation therapy with mastectomy, the authors do not even suggest that breast preservation therapy might be amenable to patients with more advanced cancers (T2 and/or N 1). Interestingly, all patients with medially located tumors, whether treated by mastectomy or lumpectomy and breast irradiation, also were treated with parasternal and supraclavicular regional irradiation. This report reflects the conservatism of many clinicians in choosing breast conservation therapy for patients with Stage I and II breast cancer. Recently reported data from the Surveillance, Epidemiology, and End Results (SEER) program of the National Cancer Institute show a slight increase in the use of breast conservation therapy throughout the period 1983 to 1986 for the nine geographical areas surveyed (2). For white females with localized breast cancer, the proportion treated with breast conservation therapy in 1985-1986 varied from 19.6 to 4 1.5%. Women under age 65 and over 75 years were more likely to undergo breast conservation surgery. However, the older women were less likely than the younger to receive postoperative breast irradiation. Nattinger et al., in a review of Medicare women age 65-79 years treated by surgery for local or regional breast cancer in 1986, also
Accepted for publication
Reprint requests to: Department of Radiation Oncology, University of Pittsburgh Health Center, Presbyterian University Hospital, Pittsburgh, PA 152 13. 1083
1 June 1992.
1084
1. J. Radiation Oncology 0 Biology 0 Physics
therapy added to lumpectomy and breast irradiation further decreases the incidence of in-breast tumor recurrence compared to lumpectomy and breast irradiation alone (6). Fisher et al. report that patients who do develop an inbreast tumor recurrence after lumpectomy + breast irradiation are at greater risk for developing distant metastasis than those who do not (3). The earlier the occurrence of the in-breast tumor recurrence after initial treatment, the sooner is the distant metastasis likely to appear. How-
Volume 23, Number 5, 1992
ever, in spite of these findings the distant disease-free and
overall survival rates are not different from those treated initially with mastectomy. Thus, in-breast tumor recurrence is considered to be a marker predicting for distant metastasis rather than the cause of the distant metastasis. It is this author’s opinion that lumpectomy and breast irradiation is appropriate treatment for practically all patients with Stage I and II breast cancer (1). The main criteria for offering breast conservation therapy is the patient’s desire to keep her breast.
REFERENCE Deutsch, M. Radiotherapy after breast conservation surgery: How much is enough? Sem. Surg. Oncol. 8: 140-146;1992. Farrow, D. C.; Hunt, W. C.; Samet, J. M. Geographic variation in the treatment of localized breast cancer. N. Engl. J. Med. 326:1097-l 101;1992. Fisher, B.; Anderson, S.; Fisher, E. R.; Redmond, C.; Wickerham, D. L.; Wolmark, N.; Mamounas, E. P.; Deutsch, M.; Margolese, R. Significance of ipsilateral breast tumour recurrence after lumpectomy. Lancet 338:327-33 1; I99 1. Fisher, B.; Bauer, M.; Margolese, R.; Poisson, R.; Pilch, Y.; Redmond, C.; Fisher, E.; Wolmark, N.; Deutsch, M.; Montague, E.; Saffer, E.; Wickerham, L.; Lerner, H.; Glass, A.; Shibata, H.; Deckers, P.; Ketcham, A.; Oishi, R.; Russell, I. 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. 312:665-673;1985. 5. Fisher, B.; Redmond, C.; Poisson, R.; Margolese, R.; Wolmark, N.; Wickerham, L.; Fisher, E.; Deutsch, M.; Caplan. R.; Pilch, Y.; Glass, A.; Shibata, H.; Lerner, H.; Terz, J.: Sidorovich, L. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or
without irradiation in the treatment of breast cancer. N. Engl. J. Med. 320:822-828;1989. 6. Fisher, B.; Wickerham, D. L.; Deutsch, M.; Anderson, S.; Redmond, C.; Fisher, E. Breast tumor recurrence following lumpectomy with and without breast irradiation: An overview of recent NSABP findings. Sem. Surg. Oncol. 8: 153160;1992. Nattinger, A. B.; Gottlieb, M. S.; Veum, J.; Yahnke, D.; Goodwin, J. S. Geographic variation in the use of breastconservation treatment for breast cancer. N. Engl. J. Med. 326:1102-l 107;1992. Sauer, R.; Rauschecker, H. F.; Schumacher, M.; Gatzemeier, W.; Schmoor, C.; Dunst, J.; Seegenschmiedt, M. H.; Marx, D. Therapy of small breast cancer: A prospective study on 1036 patients with special emphasis on prognostic factors. Int. J. Radiat. Oncol. Biol. Phys. 23:907-914;1992. Veronesi, U.; Saccozzi, R.; Del Vecchio, M.; Banfi, A.; Clemente, C.; De Lena, M.; Gallus, G.; Greco, M.; Luini, A.; Marubini, E.; Muscolino, G.; Rilke, F.; Salvadori, B.; Zecchini, A.; Zucali, R. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N. Engl. J. Med. 305:6-l 1;1981.