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Primary irradiation of stage I and stage II adenocarcinoma of the breast
0
Brief Commun!ication PRIMARY IRRADIATION OF STAGE I AND STAGE II ADENOCARCINOMA OF THE BREAST “F G. STEPHEN BROWN, M.D., $$ SIMON KRAMER M.D.,6 LUTHER BRADY, M.D.&
and DANIEL A. TOBIN, M.D.*
This preliminary report documents the experience of the 33 member institutions of the Radiation Therapy Oncology Group with the first one hundred patients entered into a registry for adenocarcinoma of the breast treated with primary radiation therapy. The age of the patients, menstrual status, indications for radiation management, degree of surgery employed, as well as the method of treatment, and subsequent results are reviewed. Local control has been achieved in 85 patients with Stage I and Stage II adenocarcinoma of the breast.
Breast, Carcinoma,
Primary irradiation.
INTRODUCTION Although control
the optimum
procedure
of adenocarcinoma
defined,
the
management
role
of
necessary
to obtain
radiation
as primary
have
of this disease is becoming
increasingly
cinema
Peters,‘.h Weber
and Hellman,”
Prosnitz
et ul.‘.’ and Wise
et ul.” have reported
growing
experience
radiation
America.
and regional becomes
with
If irradiation
control
to surgery,
then
tomy
might prompt stage when
patients
biopsy-documented
Table
local
control,
All patients invasive
must
adenocar-
in
at an and
I. U ICC staging”’
Tumor <2cm Tumor >7
T, TZ N,, N, Stage I Stage 11
of the
is more localized
of
of the breast and must have been treated with
this modality
to seek treatment
the disease
had
equal local
and preservation
evaluation
in
intact patient becomes a secondary objective. It is also conceivable that removing the fear of mastecearlier
preliminary
results, and complications.
megavoltage irradiation after 1960. Ninety-nine women and one man were included
the
management
can achieve
a valid alternative
potentially
allow
esthetic
therapy
well documented.‘.4.s
North
to
of the breast has yet to be
7-1N,, T,N, T,N, Tz N,,
more curable.
TzN,
BACKGROUND
the study.
The Radiation Therap:y Oncology Group (R.T.O.G.) is a multi-institutional s.tudy group composed of 33
27-85).
members
were
registry
(see
was initiated
these institutions of Stage cinema
Appendix
I).
December
to document
with primary
I and Stage
1975,
the experience
radiation
II (UICC
of the breast (Table
This report describes into the registry
In
of follow
age was
patients
were
The
Follow
I to I7 years with
54.2
years
(range
pre- or perimeno61 patients
up of these the average,
patients
3.4 years.
reasons for selecting radiation fell into three categories: patient pref-
primary
management
adenocar-
erence (29 patients), physician preference (49 patients), and medical contraindications to surgery (22 patients). The exact reason for physician pref-
100 patients entered
with adlequate duration
postmenopausal.
was from
of
I).
rthe initial
average
pausal (less than 2 years postmenopausal):
a
management
Staging)“’
The
Thirty-eight
up
tThis work was supported by NC1 Division of Cancer Therapy Grant CA-21661. $$,Department of Radiology, University of Vermont, College of Medicine, Burlington, VT 05401. ODepartment of Radiation Therapy, Jefferson Medical College, Philadelphia, PA 19101.
$Department of Radiation Therapy, Hahnemann Medical College, Philadelphia, PA 19201. *University of Louisville, School of Medicine, Louisville, KY 40202. Reprint requests to G. Stephen Brown, M.D., 11100 Warner Ave., Suite 162, Fountain Valley, CA 92708. II45
Radiation Oncology
1146
0
Biology 0
erence often was coupled with the patients’ avoid surgery. Further
evaluation
of
the
Physics
desires to
patient
palpable
of patients
axillary
groups, distribution tionate
biopsy
evidence
Within
by menstrual
to the number
Excisional
had no clinical
nodes (81%).
of
the T and N
status was propor-
in the study (Tables
2 and 3).
was used to establish
the diag-
nosis in 66 of the study patients. The following prowere used in addition: a needle biopsy in cedures seven patients, segmental
incisional
mastectomy
biopsy in nine patients,
7.1 T?
N,,
N,
34t
3 I6
tlncludes vage, NED
T,
18
tExcludes
The
of
irradiation
preference
varied
more
by
of initial
of many radiation
therapists
a period of up to 17 years, the irradiation variable. extremely technique were generally with
was
all patients
delivered
in-
diag-
mary. paraclavicular, tangential fields to treatment irradiation
fell into three general alone, external
per
to the internal
and axillary the breast.
over
doses and Irradiation
at 900-1200rad
being treated
irradiation
the study had recurrence three
correlated
There appeared
of
currently
metas-
patients
Twelve
within
had axillary
to the development to be no apparent
in the
of local
superiority
accepted
“best
On the
standards
more
optimal
common
of the
I5
dose.
Loco-regional
with
larger
of
patients
with
failures
primary local
tumors.
or regional
had tumors greater than 2 cm (Table
Although
the overall
follow
study is not yet adequate and
regional
failures
for
7).
up for patients final
have
judgment, occurred
in this 73%
of
within
3
years.
week I00 90
external
80
plus an external
70
OF TREATMENT
the
this group, i.e. the two needle biopsy failures,
Fourteen
local
have
it would appear that only two patients
less than
failure
sal-
in terms of local control of disease. Table 6 the dose in th site of failure relative to the T
mam-
teletherapy boost to the location of the primary, or external irradiation plus an interstitial curietherapy boost.
RESULTS
distant failure.
Table 5 shows the method of diagnosis
regions as well as The technique of categories:
with
as an irradiation
and an additional
had
than by method
survival
breast,
within
nosis. Since this study took place in many institutions under the direction
or in combination
management,“’
one male patient.
method
disease-free
and N staging and initial method of diagnosis.
2 9
7
and
surgical
by the Berkson-Gage method (Fig. I). who experienced local or regional
scored
within
method reviews
Post
I
I 5
failure.
were stitutional
overall
alone
patients
N,
I
3 patients disease-free following = no evidence of disease.
tases was
Pre
21 29
II
100
basis
12t
75 4
Local-regional + distant Distant metastases only
failure.
T,
of results
Alive with disease Local-regional only
failure
Table 3. TN staging and menstrual status
Post
12
Alive, NED? Dead, NED Dead of disease
study patients
N,,
and No.
Total
been calculated Any patient
one male patient.
Pre
II
2. No.
4. Summary
Table
Cumulative
of patients
47
tlncludes
and
in seven patients.
Table 2. Distribution
1977. Volume
population
shows that there was no bias by menopausal status within the indications for irradiation management. The majority
November-December
100
(98)
7% F
(20)
(44j’\
60 p ? in’ q 0
*--__
c?6) 50
(20)
40 30
Seventy-five patients were living without disease at an average follow up time of 3.4 years (I-17 years). Three of the patients with no evidence of disease
20
have had surgical salvage for localized recurrence. An additional 4 patients died free of disease at I, 2. 3 and 5 years after initiation of irradiation (Table 4).
0
IO I ,
2
Time,
3
4
years
Fig. 1. Cumulative survival.
5
Adenocarconoma
of the breast
l
G.
STEPHEN
BROWN
1147
Table 5. Method of diagnosis Needle Radiation
biopsy
Incisional
L-R*
No.
(rad)
F$l
No.
2 0
5000 5000-7000 5000 + boost
4 2
1
0
I 5 I
4000 + implant Total
!I 7
0 2
2 9
tLocal
biopsy
Excisional
Segmental
biopsy
dose
L-R+
L-Rt
L-RP
Fail
No.
3 53 12
2 5 2
I
0
I 3
0 0
9 77
r 10
2 2
0 0
Fail
No.
0 3 0 0 3
Fail
and regional. Table 6. Local
failures
Needle biopsy failures T N Stage Local dose (rad) 4800 T,N, 5000 T,N, Incisional biopsy failures
T N Stage
Local dose 6000 Tz N,, 6250 T,N,, Excisional biopsy failures Local dose T N Stag,e 6000 4800 5000 7000 5000 (+ 1500) 5000 (+2800t) 5500 (+3100)
T, N,, T,N,, T,N,, Tz N,, T,N,, T,N,,
T,Nu
5000 (+3000) T,N, Axillary failures T N Stage Local dose
TzN,,
5000 7000 6000
T,N,, T,N; trnterstitial
implant
CONCLUSIONS
( ) = Boost.
Table 7. Loco-regional failures
T, 7-2
N,,
N,
I
0 4
IO
Table 8. Breast
reactions*
Degree
No.
I (None) 2 (Mild to moderate) 3 (Severe)
36 59 ; 5 100
TJudged by examining
Since the patient frequently desired to preserve the breast, the esthetic results within the breast are important. In this preliminary report the evaluation of the treating physician has been used to score the local changes in the breast. Table 8 indicates that 95% of the patients were felt to have no more than moderate differences between the two breasts as a result of the irradiation delivered. Complications secondary to irradiation were limited: 3 patients developed radiation pneumonitis, 3 patients developed arm edema following irradiation. One of these patients had axillary lymph node metastases at the time of primary treatment (T?N,) and subsequently died with distant metastases. Of the 2 patients who were clinically No at the initiation of treatment, one had an axillary failure post-therapy at the time of development of arm edema. One patient within the study who had TINo stage disease had no other apparent cause for the development of this complication.
physician.
The highest priority for results of treatment of malignant disease is survival of the patient. If multiple modalities of treatment can achieve the same survival rate, the added goals of an intact patient and a limited complication rate become important. One hundred patients treated by means of irradiation are reviewed in this initial report of the R.T.O.G. Registry of patients with adenocarcinoma of the breast, Stages I and II. The preliminary results indicate that radiation therapy achieved local and regional control of disease in 85% of the study patients. Ninety-five per cent of the patients so treated had no more than moderate radiation effects within the breast. Further progress of the study will attempt to achieve the following goals: (I) Review of all histologic specimens to allow confirmation and classification of disease by a single study pathologist. (2) Further follow up and documentation of patterns of failure and complication.
1148
Radiation
November-December
Oncology 0 Biology 0 Physics
1977. Volume 2. No.
I I and No. I?
REFERENCES I. Berkson, J., Gage, R.P.: Calculation
of survival rates for cancer. Proc. Staf Meet. Mayo Clin. 25: 270-286, 1950. 2. Fletcher. G.H.: Management of localized breast cancer. Tn Textbook of Radiotherapy. 2nd Edn Philadelphia, Lea & Febiger, 1973, pp. 485-487. 3. Fletcher. G.H., Montague. E.. Nelson, A.J.: Combination of conservative surgery and irradiation for cancer of the breast. Am. J. Roentgenol. 126: 216-22. 1976. 4. Mustakallio. S.: Treatment of breast cancer by tumour extirpation and roentgen therapy instead of radical
8. Prosnitz, L.R., Goldenberg, I.S., Packard, R.A.. Leven. M.B., Harris, J.. Hellman, S., Wallner, P.E., Brady, L.W., Mansfield, C.M., Kramer, S.: Radiation therapy as initial treatment for early stage cancer of the breast without mastectomy. Cancer 39: 917-923, 1977. 9. Rissanen, P.M.: A comparison of conservative and radical surgery combined with radiotherapy in the treatment of Stage I carcinoma of the breast. Br. J. Radio/. 42: 423-426, 1969. IO. Union lnternationale Contre le Cancer: classification of malignant tumors. Geneva. UICC.
operation. J. Faculty Radiol. 6: 23-26. 1954. S. Peters, M.V.: Wedge resection and irradiation-an effective treatment in early breast cancer. J. A/H. Med. Assoc. 200: 18-21, 1967. 6. Peters. M.V.: Cutting the “Gordian knot” in early breast cancer. Ann. Royal Co//. Phys. Surg. Can. 8: 186-192. 1975. 7. Prosnitz, L.R., Goldenberg. I.S.: Radiation therapy as primary treatment for early stage carcinoma of the breast. Cancer 35: 3587-1596. 1975.
Radiation
2nd Edn, pp. 51-55. I I. Weber, E.. Hellman, S.: Radiation as primary treatment for local control of breast carcinoma. J. Am. Med. Assoc. 234: 608-61 I. 1975. 12. Wise, L.. Mason. A.Y.. Ackerman. L.V.: Local excision and irradiation: an alternative method for the treatment of early mammary cancer. Ann. Surg. 174: 392-401.197 I
Oncology Group
Therapy
FULL
MEMBERS
University of California/San Francisco University of Southern California LACKJSC Medical Center Thomas Jefferson University Hospital Medical Center Hospital of Vermont University of Washington Hospital
American Oncologic Hospital Ellis Fischel State Cancer Hospital Hahnemann Medical College & Hospital LDS Hospital University of Louisville Loyola University Medical Center New York University Medical Center
PROVISIONAL
Boston University Albert Einstein
Medical Center
Medical Center
TNM 1974.
MEMBERS
Brief Commun!ication PRIMARY IRRADIATION OF STAGE I AND STAGE II ADENOCARCINOMA OF THE BREAST “F G. STEPHEN BROWN, M.D., $$ SIMON KRAMER M.D.,6 LUTHER BRADY, M.D.&
and DANIEL A. TOBIN, M.D.*
This preliminary report documents the experience of the 33 member institutions of the Radiation Therapy Oncology Group with the first one hundred patients entered into a registry for adenocarcinoma of the breast treated with primary radiation therapy. The age of the patients, menstrual status, indications for radiation management, degree of surgery employed, as well as the method of treatment, and subsequent results are reviewed. Local control has been achieved in 85 patients with Stage I and Stage II adenocarcinoma of the breast.
Breast, Carcinoma,
Primary irradiation.
INTRODUCTION Although control
the optimum
procedure
of adenocarcinoma
defined,
the
management
role
of
necessary
to obtain
radiation
as primary
have
of this disease is becoming
increasingly
cinema
Peters,‘.h Weber
and Hellman,”
Prosnitz
et ul.‘.’ and Wise
et ul.” have reported
growing
experience
radiation
America.
and regional becomes
with
If irradiation
control
to surgery,
then
tomy
might prompt stage when
patients
biopsy-documented
Table
local
control,
All patients invasive
must
adenocar-
in
at an and
I. U ICC staging”’
Tumor <2cm Tumor >7
T, TZ N,, N, Stage I Stage 11
of the
is more localized
of
of the breast and must have been treated with
this modality
to seek treatment
the disease
had
equal local
and preservation
evaluation
in
intact patient becomes a secondary objective. It is also conceivable that removing the fear of mastecearlier
preliminary
results, and complications.
megavoltage irradiation after 1960. Ninety-nine women and one man were included
the
management
can achieve
a valid alternative
potentially
allow
esthetic
therapy
well documented.‘.4.s
North
to
of the breast has yet to be
7-1N,, T,N, T,N, Tz N,,
more curable.
TzN,
BACKGROUND
the study.
The Radiation Therap:y Oncology Group (R.T.O.G.) is a multi-institutional s.tudy group composed of 33
27-85).
members
were
registry
(see
was initiated
these institutions of Stage cinema
Appendix
I).
December
to document
with primary
I and Stage
1975,
the experience
radiation
II (UICC
of the breast (Table
This report describes into the registry
In
of follow
age was
patients
were
The
Follow
I to I7 years with
54.2
years
(range
pre- or perimeno61 patients
up of these the average,
patients
3.4 years.
reasons for selecting radiation fell into three categories: patient pref-
primary
management
adenocar-
erence (29 patients), physician preference (49 patients), and medical contraindications to surgery (22 patients). The exact reason for physician pref-
100 patients entered
with adlequate duration
postmenopausal.
was from
of
I).
rthe initial
average
pausal (less than 2 years postmenopausal):
a
management
Staging)“’
The
Thirty-eight
up
tThis work was supported by NC1 Division of Cancer Therapy Grant CA-21661. $$,Department of Radiology, University of Vermont, College of Medicine, Burlington, VT 05401. ODepartment of Radiation Therapy, Jefferson Medical College, Philadelphia, PA 19101.
$Department of Radiation Therapy, Hahnemann Medical College, Philadelphia, PA 19201. *University of Louisville, School of Medicine, Louisville, KY 40202. Reprint requests to G. Stephen Brown, M.D., 11100 Warner Ave., Suite 162, Fountain Valley, CA 92708. II45
Radiation Oncology
1146
0
Biology 0
erence often was coupled with the patients’ avoid surgery. Further
evaluation
of
the
Physics
desires to
patient
palpable
of patients
axillary
groups, distribution tionate
biopsy
evidence
Within
by menstrual
to the number
Excisional
had no clinical
nodes (81%).
of
the T and N
status was propor-
in the study (Tables
2 and 3).
was used to establish
the diag-
nosis in 66 of the study patients. The following prowere used in addition: a needle biopsy in cedures seven patients, segmental
incisional
mastectomy
biopsy in nine patients,
7.1 T?
N,,
N,
34t
3 I6
tlncludes vage, NED
T,
18
tExcludes
The
of
irradiation
preference
varied
more
by
of initial
of many radiation
therapists
a period of up to 17 years, the irradiation variable. extremely technique were generally with
was
all patients
delivered
in-
diag-
mary. paraclavicular, tangential fields to treatment irradiation
fell into three general alone, external
per
to the internal
and axillary the breast.
over
doses and Irradiation
at 900-1200rad
being treated
irradiation
the study had recurrence three
correlated
There appeared
of
currently
metas-
patients
Twelve
within
had axillary
to the development to be no apparent
in the
of local
superiority
accepted
“best
On the
standards
more
optimal
common
of the
I5
dose.
Loco-regional
with
larger
of
patients
with
failures
primary local
tumors.
or regional
had tumors greater than 2 cm (Table
Although
the overall
follow
study is not yet adequate and
regional
failures
for
7).
up for patients final
have
judgment, occurred
in this 73%
of
within
3
years.
week I00 90
external
80
plus an external
70
OF TREATMENT
the
this group, i.e. the two needle biopsy failures,
Fourteen
local
have
it would appear that only two patients
less than
failure
sal-
in terms of local control of disease. Table 6 the dose in th site of failure relative to the T
mam-
teletherapy boost to the location of the primary, or external irradiation plus an interstitial curietherapy boost.
RESULTS
distant failure.
Table 5 shows the method of diagnosis
regions as well as The technique of categories:
with
as an irradiation
and an additional
had
than by method
survival
breast,
within
nosis. Since this study took place in many institutions under the direction
or in combination
management,“’
one male patient.
method
disease-free
and N staging and initial method of diagnosis.
2 9
7
and
surgical
by the Berkson-Gage method (Fig. I). who experienced local or regional
scored
within
method reviews
Post
I
I 5
failure.
were stitutional
overall
alone
patients
N,
I
3 patients disease-free following = no evidence of disease.
tases was
Pre
21 29
II
100
basis
12t
75 4
Local-regional + distant Distant metastases only
failure.
T,
of results
Alive with disease Local-regional only
failure
Table 3. TN staging and menstrual status
Post
12
Alive, NED? Dead, NED Dead of disease
study patients
N,,
and No.
Total
been calculated Any patient
one male patient.
Pre
II
2. No.
4. Summary
Table
Cumulative
of patients
47
tlncludes
and
in seven patients.
Table 2. Distribution
1977. Volume
population
shows that there was no bias by menopausal status within the indications for irradiation management. The majority
November-December
100
(98)
7% F
(20)
(44j’\
60 p ? in’ q 0
*--__
c?6) 50
(20)
40 30
Seventy-five patients were living without disease at an average follow up time of 3.4 years (I-17 years). Three of the patients with no evidence of disease
20
have had surgical salvage for localized recurrence. An additional 4 patients died free of disease at I, 2. 3 and 5 years after initiation of irradiation (Table 4).
0
IO I ,
2
Time,
3
4
years
Fig. 1. Cumulative survival.
5
Adenocarconoma
of the breast
l
G.
STEPHEN
BROWN
1147
Table 5. Method of diagnosis Needle Radiation
biopsy
Incisional
L-R*
No.
(rad)
F$l
No.
2 0
5000 5000-7000 5000 + boost
4 2
1
0
I 5 I
4000 + implant Total
!I 7
0 2
2 9
tLocal
biopsy
Excisional
Segmental
biopsy
dose
L-R+
L-Rt
L-RP
Fail
No.
3 53 12
2 5 2
I
0
I 3
0 0
9 77
r 10
2 2
0 0
Fail
No.
0 3 0 0 3
Fail
and regional. Table 6. Local
failures
Needle biopsy failures T N Stage Local dose (rad) 4800 T,N, 5000 T,N, Incisional biopsy failures
T N Stage
Local dose 6000 Tz N,, 6250 T,N,, Excisional biopsy failures Local dose T N Stag,e 6000 4800 5000 7000 5000 (+ 1500) 5000 (+2800t) 5500 (+3100)
T, N,, T,N,, T,N,, Tz N,, T,N,, T,N,,
T,Nu
5000 (+3000) T,N, Axillary failures T N Stage Local dose
TzN,,
5000 7000 6000
T,N,, T,N; trnterstitial
implant
CONCLUSIONS
( ) = Boost.
Table 7. Loco-regional failures
T, 7-2
N,,
N,
I
0 4
IO
Table 8. Breast
reactions*
Degree
No.
I (None) 2 (Mild to moderate) 3 (Severe)
36 59 ; 5 100
TJudged by examining
Since the patient frequently desired to preserve the breast, the esthetic results within the breast are important. In this preliminary report the evaluation of the treating physician has been used to score the local changes in the breast. Table 8 indicates that 95% of the patients were felt to have no more than moderate differences between the two breasts as a result of the irradiation delivered. Complications secondary to irradiation were limited: 3 patients developed radiation pneumonitis, 3 patients developed arm edema following irradiation. One of these patients had axillary lymph node metastases at the time of primary treatment (T?N,) and subsequently died with distant metastases. Of the 2 patients who were clinically No at the initiation of treatment, one had an axillary failure post-therapy at the time of development of arm edema. One patient within the study who had TINo stage disease had no other apparent cause for the development of this complication.
physician.
The highest priority for results of treatment of malignant disease is survival of the patient. If multiple modalities of treatment can achieve the same survival rate, the added goals of an intact patient and a limited complication rate become important. One hundred patients treated by means of irradiation are reviewed in this initial report of the R.T.O.G. Registry of patients with adenocarcinoma of the breast, Stages I and II. The preliminary results indicate that radiation therapy achieved local and regional control of disease in 85% of the study patients. Ninety-five per cent of the patients so treated had no more than moderate radiation effects within the breast. Further progress of the study will attempt to achieve the following goals: (I) Review of all histologic specimens to allow confirmation and classification of disease by a single study pathologist. (2) Further follow up and documentation of patterns of failure and complication.
1148
Radiation
November-December
Oncology 0 Biology 0 Physics
1977. Volume 2. No.
I I and No. I?
REFERENCES I. Berkson, J., Gage, R.P.: Calculation
of survival rates for cancer. Proc. Staf Meet. Mayo Clin. 25: 270-286, 1950. 2. Fletcher. G.H.: Management of localized breast cancer. Tn Textbook of Radiotherapy. 2nd Edn Philadelphia, Lea & Febiger, 1973, pp. 485-487. 3. Fletcher. G.H., Montague. E.. Nelson, A.J.: Combination of conservative surgery and irradiation for cancer of the breast. Am. J. Roentgenol. 126: 216-22. 1976. 4. Mustakallio. S.: Treatment of breast cancer by tumour extirpation and roentgen therapy instead of radical
8. Prosnitz, L.R., Goldenberg, I.S., Packard, R.A.. Leven. M.B., Harris, J.. Hellman, S., Wallner, P.E., Brady, L.W., Mansfield, C.M., Kramer, S.: Radiation therapy as initial treatment for early stage cancer of the breast without mastectomy. Cancer 39: 917-923, 1977. 9. Rissanen, P.M.: A comparison of conservative and radical surgery combined with radiotherapy in the treatment of Stage I carcinoma of the breast. Br. J. Radio/. 42: 423-426, 1969. IO. Union lnternationale Contre le Cancer: classification of malignant tumors. Geneva. UICC.
operation. J. Faculty Radiol. 6: 23-26. 1954. S. Peters, M.V.: Wedge resection and irradiation-an effective treatment in early breast cancer. J. A/H. Med. Assoc. 200: 18-21, 1967. 6. Peters. M.V.: Cutting the “Gordian knot” in early breast cancer. Ann. Royal Co//. Phys. Surg. Can. 8: 186-192. 1975. 7. Prosnitz, L.R., Goldenberg. I.S.: Radiation therapy as primary treatment for early stage carcinoma of the breast. Cancer 35: 3587-1596. 1975.
Radiation
2nd Edn, pp. 51-55. I I. Weber, E.. Hellman, S.: Radiation as primary treatment for local control of breast carcinoma. J. Am. Med. Assoc. 234: 608-61 I. 1975. 12. Wise, L.. Mason. A.Y.. Ackerman. L.V.: Local excision and irradiation: an alternative method for the treatment of early mammary cancer. Ann. Surg. 174: 392-401.197 I
Oncology Group
Therapy
FULL
MEMBERS
University of California/San Francisco University of Southern California LACKJSC Medical Center Thomas Jefferson University Hospital Medical Center Hospital of Vermont University of Washington Hospital
American Oncologic Hospital Ellis Fischel State Cancer Hospital Hahnemann Medical College & Hospital LDS Hospital University of Louisville Loyola University Medical Center New York University Medical Center
PROVISIONAL
Boston University Albert Einstein
Medical Center
Medical Center
TNM 1974.
MEMBERS