- Email: [email protected]
“Local” Treatment of Early Breast Cancer
Symposium on Breast Cancer
"Local" Treatment of Early Breast Cancer
M. Vera Peters, O.C., M.D., F.R.C.P(C)*
AUTHOR"S NoTE: This symposium on breast cancer pays well-deserved tribute to Dr. George Crile and Dr. Philip Strax. Both have impressed me many times in the past because of their open-mindedness, honesty, and dedication to their respective interests. This article summarizes my present views on the local treatment of early breast cancer and on the gradual changes that have evolved in my treatment philosophy, which I present as a measure of esteem for these two physicians.
Breast cancer is now known to be a systemic disease. Long before the primary tumor can be detected clinically, viable cancer cells are shed from the growing tumor and enter the blood stream. The majority are destroyed, but some are disseminated to any receptive body tissue. This knowledge, revealed more than a decade ago, has explained many retrospective observations and has commanded a second look at our treatment policies. The former emphasis on local treatment has been transferred to systemic therapy. Patients who refused mastectomy were the true pioneers of conservative treatment of early breast cancer. Our apprehension about their outlook soon changed to interest, and later to conviction on observing that the majority were free of disease 10 to 20 years later. Conservative treatment for early breast cancer was overwhelmingly opposed until the recent change in concept of the mode of spread of the disease. The reriwval or destruction of the primary breast tumor, which eliminates the source of new cancer cells, is now acknowledged to be the only "local" treatment capable of prolonging survival. Using total survival as the sole measure of success, lumpectomy alone is ample treatment for breast cancer in stages T 1 N0 or T 2 N 0 • The only major concern is the higher incidence of recurrent disease in breast. Although the benefits of lumpectomy alone far outweigh that risk, it is acknowledged that 15 to 25 per cent develop a second malignant lump in the same breast, usually within 2 years. Most of the second lumps are not ominous, however. *Consultant Physician, The Princess Margaret Hospital, Toronto, and Consultant Oncologist, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
Surgical Clinics of North America-Val. 64, No. 6, December 1984
1151
1152
M.
VERA PETERS
The location of the second site of disease is important in prognosis. Approximately two-thirds of the recurrences develop in a separate area with no encroachment on the previous operative site. In such instances, the outlook is still favorable, and the majority of patients survive more than 10 years without clinical evidence of metastases. A second local excision may be adequate treatment, depending on the size of the breast. In the remaining one-third of recurrences, the second lump is located within or overlapping the boundary of the previous excision site. These neoplasms are definite recurrences and should be considered metastatic. Such a recurrence is sometimes coincident with enlarging lymph nodes in the axilla. After removal of the breast recurrence, by partial or total mastectomy, systemic therapy is the most important need for the patient. The combination of local excision and radiation has encountered more popularity than excision alone, because the recurrence rate in breast is reduced to approximately 7 per cent. However, improved survival up to 15 years cannot be demonstrated, and the risk oflate radiation complications becomes a threat. Fibrosis becomes readily apparent around the tenth year and slowly progresses. If only the breast is irradiated after excision of the primary, using a moderate tumor dose of 4,000 rads over 3 weeks, for example, a slight shrinkage of the entire breast can be detected after 10 years. When proximal lymph node regions are also irradiated, the circulation to the breast is further reduced, and a more marked atrophy of the breast ensues. Higher tumor doses delivered to breast and lymphatic regions compound this risk, and distressing complications in any of the tissues irradiated become a possibility. In addition, a recurrence, especially around the excision area, is more difficult to detect early in the radiated breast. Recurrences have been mistaken for localized radiation fibrosis. To avoid a true recurrence, some have prescribed a booster dose of radiation to the tumor bed, but the resultant localized scarring detracts from the cosmetic effect. Therefore, routine radiation following local excision, while decreasing the local recurrence rate, does not improve survival; it also cannot be justified for long-term cosmesis, and it subjects the patient to additional risks of late complications. Is it possible to anticipate those who have a high risk of developing an ominous recurrence after lumpectomy? The pathologic findings in the serial sections of all tissues removed provide the best clues. When the major component of the tumor mass is intraductal disease (at times involving several ducts), or if the mass is chiefly an intraductal cyst filled with necrotic tumor, or if extension along the lining of a duct beyond the main mass is discovered, a true recurrence in or around the original site can be anticipated. The degree of differentiation in the predominant cancer cells is also helpful in formulating the prognosis. Pleomorphism and/or a poorly differentiated cancer cell population suggest a higher risk of distant metastases, rather than any form of local recurrence. Whenever a local recurrence can be anticipated according to pathologic findings, a second surgical procedure-either a wider excision or a mastec-
"LoCAL "TREATMENT OF EARLY BREAST CANCER
1153
tomy, in my opinion-is preferable to radiation, but the patient's wishes should be considered. The second procedure can safely be delayed until a total assessment is complete. We include in this assessment, carcinoembryonic antigen test (CEA), hemogram, liver function tests, and liver and bone scans, as well as bilateral internal mammary and axillary scintigraphy. Xerography of the axilla is also occasionally helpful. These investigations and the details of pathologic findings will then guide the decision making; the need for further local treatment, systemic therapy, or no treatment becomes apparent. Finally, our realization that involved regional lymph nodes represent metastases was the most dramatic deviation from previous popular beliefs. Reflecting on the total spectrum of breast cancer presentations, we must accept positive axillary nodes as the first detectable evidence of metastatic disease in an overwhelming majority of patients. In early breast cancer, especially in stage T 1 N 0 , surgeons no longer worry about leaving the clinically negative axilla untouched. In my opinion, axillary dissection or radiation is contraindicated because the clinically uninvolved and untreated axilla offers an unparalleled follow-up tool. If and when enlarging axillary nodes are discovered on future follow-up, reactivation of the entire disease process can be assumed, even if other distant sites cannot be detected at that point. A needle aspiration biopsy can often provide pathologic proof. The palpably enlarged axillary node can then provide a tangible and measurable index of the effectiveness of systemic therapy. If the vascular system has previously been damaged by surgery, or radiation, or both, recurrent axillary nodes respond poorly or negatively to systemic therapy, even when there is other evidence of remission, such as marked reduction in the CEA index. Thus, the advantages achieved by avoiding any treatment to the axilla or other regional nodes far outweigh the risk of aggressive prophylactic treatment. In this early stage of disease, the 10-year survival rate is between 75 and 85 per cent, depending on the population studied. Thus the probability of finding unsuspected positive axillary nodes, by performing routine axillary dissections along with the excision of the primary, is extremely low. Quite apart from the therapeutic alternatives discussed above, the important influence of the patient's potential to control her own disease cannot be overlooked. Probably a superior immune mechanism is the major factor allowing the majority to postpone metastatic disease fo/ many years. Their immune potential is reflected by their state of physical and mental health, and by the lymphocyte count. Although investigative units currently have highly sophisticated tests of immune sensitivity, I would hope to see readily available and simple tests developed in the near future.
SUMMARY
The majority ofT 1 N0 and T 2 N 0 primary breast tumors can be adequately treated by segmental resection. The need for additional local treatment can often be determined by pathologic findings. Should this need arise, my
1154
M.
VERA PETERS
choice is a wider excision if a satisfactory cosmetic effect can be maintained, but mastectomy or breast irradiation may be more suitable for some. The patient's preference should be respected. The metastatic nature of involved regional nodes eliminates the necessity to radiate or remove them on a prophylactic basis. A plea is made to avoid both dissection of, and radiation to, the clinically uninvolved axillae in early presentations. Whenever recurrent disease in the axilla is discovered on follow-up, distant metastases are assumed to be active and systemic therapy instituted. Metastatic axillary nodes then become an important, measurable guide in assessing the value of the systemic treatment prescribed. Every decision is critical in advising patients with early breast cancer who have a long-range life expectancy. The quality of their future should not be endangered by aggressive "local" treatment. ACKNOWLEDGMENTS I am grateful to the General Surgical Staff of Oakville Trafalgar Memorial Hospital, Oakville, Ontario, for allowing me to cooperate in the management of many patients with early-stage breast cancer during the past few years. This enriched experience has consolidated my previous views and has broadened my perspectives. M. Vera Peters, O.C., M.D. 627 Lyons Lane, # 101 Oakville, Ontario, Canada L6J 5Z7
"Local" Treatment of Early Breast Cancer
M. Vera Peters, O.C., M.D., F.R.C.P(C)*
AUTHOR"S NoTE: This symposium on breast cancer pays well-deserved tribute to Dr. George Crile and Dr. Philip Strax. Both have impressed me many times in the past because of their open-mindedness, honesty, and dedication to their respective interests. This article summarizes my present views on the local treatment of early breast cancer and on the gradual changes that have evolved in my treatment philosophy, which I present as a measure of esteem for these two physicians.
Breast cancer is now known to be a systemic disease. Long before the primary tumor can be detected clinically, viable cancer cells are shed from the growing tumor and enter the blood stream. The majority are destroyed, but some are disseminated to any receptive body tissue. This knowledge, revealed more than a decade ago, has explained many retrospective observations and has commanded a second look at our treatment policies. The former emphasis on local treatment has been transferred to systemic therapy. Patients who refused mastectomy were the true pioneers of conservative treatment of early breast cancer. Our apprehension about their outlook soon changed to interest, and later to conviction on observing that the majority were free of disease 10 to 20 years later. Conservative treatment for early breast cancer was overwhelmingly opposed until the recent change in concept of the mode of spread of the disease. The reriwval or destruction of the primary breast tumor, which eliminates the source of new cancer cells, is now acknowledged to be the only "local" treatment capable of prolonging survival. Using total survival as the sole measure of success, lumpectomy alone is ample treatment for breast cancer in stages T 1 N0 or T 2 N 0 • The only major concern is the higher incidence of recurrent disease in breast. Although the benefits of lumpectomy alone far outweigh that risk, it is acknowledged that 15 to 25 per cent develop a second malignant lump in the same breast, usually within 2 years. Most of the second lumps are not ominous, however. *Consultant Physician, The Princess Margaret Hospital, Toronto, and Consultant Oncologist, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
Surgical Clinics of North America-Val. 64, No. 6, December 1984
1151
1152
M.
VERA PETERS
The location of the second site of disease is important in prognosis. Approximately two-thirds of the recurrences develop in a separate area with no encroachment on the previous operative site. In such instances, the outlook is still favorable, and the majority of patients survive more than 10 years without clinical evidence of metastases. A second local excision may be adequate treatment, depending on the size of the breast. In the remaining one-third of recurrences, the second lump is located within or overlapping the boundary of the previous excision site. These neoplasms are definite recurrences and should be considered metastatic. Such a recurrence is sometimes coincident with enlarging lymph nodes in the axilla. After removal of the breast recurrence, by partial or total mastectomy, systemic therapy is the most important need for the patient. The combination of local excision and radiation has encountered more popularity than excision alone, because the recurrence rate in breast is reduced to approximately 7 per cent. However, improved survival up to 15 years cannot be demonstrated, and the risk oflate radiation complications becomes a threat. Fibrosis becomes readily apparent around the tenth year and slowly progresses. If only the breast is irradiated after excision of the primary, using a moderate tumor dose of 4,000 rads over 3 weeks, for example, a slight shrinkage of the entire breast can be detected after 10 years. When proximal lymph node regions are also irradiated, the circulation to the breast is further reduced, and a more marked atrophy of the breast ensues. Higher tumor doses delivered to breast and lymphatic regions compound this risk, and distressing complications in any of the tissues irradiated become a possibility. In addition, a recurrence, especially around the excision area, is more difficult to detect early in the radiated breast. Recurrences have been mistaken for localized radiation fibrosis. To avoid a true recurrence, some have prescribed a booster dose of radiation to the tumor bed, but the resultant localized scarring detracts from the cosmetic effect. Therefore, routine radiation following local excision, while decreasing the local recurrence rate, does not improve survival; it also cannot be justified for long-term cosmesis, and it subjects the patient to additional risks of late complications. Is it possible to anticipate those who have a high risk of developing an ominous recurrence after lumpectomy? The pathologic findings in the serial sections of all tissues removed provide the best clues. When the major component of the tumor mass is intraductal disease (at times involving several ducts), or if the mass is chiefly an intraductal cyst filled with necrotic tumor, or if extension along the lining of a duct beyond the main mass is discovered, a true recurrence in or around the original site can be anticipated. The degree of differentiation in the predominant cancer cells is also helpful in formulating the prognosis. Pleomorphism and/or a poorly differentiated cancer cell population suggest a higher risk of distant metastases, rather than any form of local recurrence. Whenever a local recurrence can be anticipated according to pathologic findings, a second surgical procedure-either a wider excision or a mastec-
"LoCAL "TREATMENT OF EARLY BREAST CANCER
1153
tomy, in my opinion-is preferable to radiation, but the patient's wishes should be considered. The second procedure can safely be delayed until a total assessment is complete. We include in this assessment, carcinoembryonic antigen test (CEA), hemogram, liver function tests, and liver and bone scans, as well as bilateral internal mammary and axillary scintigraphy. Xerography of the axilla is also occasionally helpful. These investigations and the details of pathologic findings will then guide the decision making; the need for further local treatment, systemic therapy, or no treatment becomes apparent. Finally, our realization that involved regional lymph nodes represent metastases was the most dramatic deviation from previous popular beliefs. Reflecting on the total spectrum of breast cancer presentations, we must accept positive axillary nodes as the first detectable evidence of metastatic disease in an overwhelming majority of patients. In early breast cancer, especially in stage T 1 N 0 , surgeons no longer worry about leaving the clinically negative axilla untouched. In my opinion, axillary dissection or radiation is contraindicated because the clinically uninvolved and untreated axilla offers an unparalleled follow-up tool. If and when enlarging axillary nodes are discovered on future follow-up, reactivation of the entire disease process can be assumed, even if other distant sites cannot be detected at that point. A needle aspiration biopsy can often provide pathologic proof. The palpably enlarged axillary node can then provide a tangible and measurable index of the effectiveness of systemic therapy. If the vascular system has previously been damaged by surgery, or radiation, or both, recurrent axillary nodes respond poorly or negatively to systemic therapy, even when there is other evidence of remission, such as marked reduction in the CEA index. Thus, the advantages achieved by avoiding any treatment to the axilla or other regional nodes far outweigh the risk of aggressive prophylactic treatment. In this early stage of disease, the 10-year survival rate is between 75 and 85 per cent, depending on the population studied. Thus the probability of finding unsuspected positive axillary nodes, by performing routine axillary dissections along with the excision of the primary, is extremely low. Quite apart from the therapeutic alternatives discussed above, the important influence of the patient's potential to control her own disease cannot be overlooked. Probably a superior immune mechanism is the major factor allowing the majority to postpone metastatic disease fo/ many years. Their immune potential is reflected by their state of physical and mental health, and by the lymphocyte count. Although investigative units currently have highly sophisticated tests of immune sensitivity, I would hope to see readily available and simple tests developed in the near future.
SUMMARY
The majority ofT 1 N0 and T 2 N 0 primary breast tumors can be adequately treated by segmental resection. The need for additional local treatment can often be determined by pathologic findings. Should this need arise, my
1154
M.
VERA PETERS
choice is a wider excision if a satisfactory cosmetic effect can be maintained, but mastectomy or breast irradiation may be more suitable for some. The patient's preference should be respected. The metastatic nature of involved regional nodes eliminates the necessity to radiate or remove them on a prophylactic basis. A plea is made to avoid both dissection of, and radiation to, the clinically uninvolved axillae in early presentations. Whenever recurrent disease in the axilla is discovered on follow-up, distant metastases are assumed to be active and systemic therapy instituted. Metastatic axillary nodes then become an important, measurable guide in assessing the value of the systemic treatment prescribed. Every decision is critical in advising patients with early breast cancer who have a long-range life expectancy. The quality of their future should not be endangered by aggressive "local" treatment. ACKNOWLEDGMENTS I am grateful to the General Surgical Staff of Oakville Trafalgar Memorial Hospital, Oakville, Ontario, for allowing me to cooperate in the management of many patients with early-stage breast cancer during the past few years. This enriched experience has consolidated my previous views and has broadened my perspectives. M. Vera Peters, O.C., M.D. 627 Lyons Lane, # 101 Oakville, Ontario, Canada L6J 5Z7