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Mastectomy versus lumpectomy for breast cancer

Italian study [1]
Results
US study [2]
Results
Comment

With early, non-invasive breast cancer, surgery to remove the cancer is usually the treatment of choice. But what type of surgery? Should it be radical - removal of the whole breast - or minimal, removal of the lump and conserving the breast? Randomised trials have been criticised because with small breast cancers follow-up must be for a long time to be sure that differences in recurrence locally or at distant sites are not being missed. Two studies have now reported on 20-year follow-up, and both confirm that lumpectomy plus irradiation gives similar results to radical mastectomy [1,2].

Italian study [1]

Between 1973 and 1980, 701 women with breast cancers with a maximal diameter of 2 cm or less (stage T1) and no palpable nodes and who were younger than 70 years were recruited. They were randomised to radical mastectomy or breast-conserving surgery with complete axial dissection and postoperative irradiation to the affected breast. From 1976 all patients with positive axillary nodes were additionally given 12 monthly cycles of chemotherapy.

Patients were seen every three months for the first 10 years, and annually thereafter. Annual visits included mammography.

Results

The average age of the women was 51 years, and the median follow up was 20 years. Only three women were lost to follow up. In almost all women the primary cancer was palpable. The two groups of women had similar baseline characteristics for menopausal status, size and site of tumour and axillary node metastases.

The results are shown in Table 1. The only significant difference was in the rate of local recurrence, at 2.3% for radical mastectomy and 8.6% for breast-conserving surgery. There was no difference in rates of contralateral breast cancer, distant metastases, other cancers, breast cancer deaths or all-cause mortality.

Table 1: Twenty-year results of Italian randomised trial of breast cancer surgery

Radical mastectomy

Breast-conserving surgery

Number 349 352

Outcome [number, (%)]

Local recurrence 8 (2.3) 30 (8.6)
Contralateral breast cancer 34 (9.7) 29 (8.3)
Distant metastases 83 (24) 82 (24)
Other primary cancers 30 (8.6) 31 (8.9)
All cause death 152 (44) 156 (44)
Breast cancer death 86 (25) 91 (26)

US study [2]

Between 1976 and 1984 women with breast cancers with a maximal diameter of 4 cm or less and with negative or positive axillary nodes were randomised to radical mastectomy, lumpectomy, or lumpectomy plus breast irradiation.

Results

There were 1,851 women followed up for an average of 20 years. About 60% of women were older than 50 years. The groups had similar baseline characteristics for menopausal status, size and site of tumour and axillary node metastases.

The results are shown in Table 2. The only significant difference was in the rate of local recurrence, at 2.7% for breast-conserving surgery with irradiation but higher for radical mastectomy and lumpectomy alone. There was no difference in rates of contralateral breast cancer, distant metastases, other cancers, breast cancer deaths or all-cause mortality.

Table 2: Twenty-year results of US randomised trial of breast cancer surgery

Radical mastectomy

Lumpectomy alone

Lumpectomy plus irradiation

Number 589 634 628

Outcome [number, (%)]

Local recurrence 60 (10) 58 (8.8) 17 (2.7)
Contralateral breast cancer 50 (8.5) 56 (8.8) 59 (9.4)
Distant metastases 132 (22) 158 (25) 163 (26)
Other primary cancers 43 (7.3) 32 (5.0) 49 (7.8)
All cause death 371 (63) 408 (64) 391 (62)

The cumulative incidence of death from any cause in all 1,851 women was 54% at 20 years, and 40% died after a recurrence or diagnosis of cancer in the contralateral breast.

Comment

Results were consistent, with the exception that the Italian study found lower rates of local recurrence with mastectomy, albeit with few actual events. Meta-analyses of trials in breast cancer have found no significant difference between mastectomy and lumpectomy at 10 years.

The finding of these two trials of no important difference at 20 years provides even more confidence that, where appropriate, lumpectomy plus irradiation is safe and effective treatment for early breast cancer.

Remarkable in these trials is the high degree of follow up over 20 years, and the consistency of the results. Together with other evidence that mastectomy does not have any survival advantage over lumpectomy, the lack of superiority of mastectomy over breast-conserving surgery is pretty much nailed down.

The question of which women with breast cancer should be offered which treatment is eloquently addressed in an accompanying article [3]. The thrust of this is that breast-conserving surgery is underused, at least in the USA.

References:

  1. U Veronesi et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. New England Journal of Medicine 2002 347: 1227-1232.
  2. B Fisher et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. New England Journal of Medicine 2002 347: 1233-1241.
  3. M Morrow. Rational local therapy for breast cancer. New England Journal of Medicine 2002 347: 1270-1271.
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