Mastectomy vs Breast Conservation Therapy

• NSABP B-04:
  • A Protocol for the Evaluation of Radical Mastectomy and Total Mastectomy With and Without Radiation in the Primary Treatment of Cancer of the Female Breast
  • Enrolled 1,079 patients with clinically node-negative disease:
    • Randomized them to radical mastectomy (RM), total mastectomy (TM) plus local-regional axillary irradiation, or TM alone
  • An additional 586 patients with clinically node-positive disease:
    • Were randomized to RM or TM plus radiation
  • An important point of this trial is that none of these patients received systemic therapy
  • After 25 years of follow-up:
    • The study showed no significant difference in long-term outcome between:
      • Clinically node-negative patients who received RM and those who received TM with or without radiation, or between clinically node-positive patients who received RM vs.TM with nodal irradiation
    • When comparing the hazard ratio for death within the two arms:
      • The results show no survival advantage from RM
  • In patients with clinically node-negative disease:
    • Pathologic examination of the mastectomy specimen in patients treated with radical mastectomy revealed that 40% of the patients had pathologically positive nodes:
      • However, only 19% of patients treated with TM alone and no axillary surgery had an axillary recurrence:
        • Suggesting that not all occult axillary disease will progress into clinically meaningful disease, even in the absence of systemic therapy
• NSABP B-06:
  • Phase III Total Mastectomy / Axillary Dissection vs Segmental Mastectomy / Axillary Dissection with or without Radiotherapy for Potentially Curable Breast Carcinoma
  • Compared lumpectomy and axillary node dissection with or without breast irradiation with modified radical mastectomy (MRM):
    • In patients with tumors 4 cm or less in greatest diameter
  • The results of this trial demonstrating equivalent survival between the two surgical options:
    • Establish BCS as a viable surgical option for most patients with invasive breast cancer
• The Milan I trial:
  • Compared 701 patients with invasive breast cancer up to 2 cm in size without clinically positive axillary lymph nodes:
    • Randomized them into those who received radical mastectomy and those who received quadrantectomy plus axillary dissection and radiotherapy
  • A recent analysis of the trial showed no differences in OS between the two study groups
• The NSABP B-17:
  • Phase III Randomized Study of Postoperative Radiotherapy Following Segmental Mastectomy and Axillary Dissection in Patients with Noninvasive Intraductal Adenocarcinoma of the Breast:
    • Compared lumpectomy alone to lumpectomy plus breast irradiation in 818 patients with localized ductal carcinoma in situ
  • This trial concluded that radiotherapy did not improve OS but that it did significantly decrease the rate of invasive or in situ in breast tumor recurrence in the ipsilateral breast
• The EORTC Trial 10801:
  • Was a randomized multicenter trial that compared breast-conserving therapy with MRM for patients with invasive breast cancer less than 5 cm in diameter
  • At 10 years, there was no difference between the two groups in OS or in distant metastasis-free rates
  • Locoregional recurrence at 10 years was:
    • 12% for the mastectomy group and 20% for the breast-conserving therapy group

References

1. Fisher B, Montague E, Redmond C, Barton B, Borland D, Fisher ER, et al. Comparison of radical mastectomy with alternative treatments for primary breast cancer: a first report of results from a prospective randomized clinical trial. Cancer. 1977;39(6 Suppl):2827-2839.

2. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, 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. N Engl J Med. 2002;347(16):1233-1241.

3. Mamounas EP, Wickerham DL, Fisher B, Geyer CE, Julian TB, Wolmark N. The NSABP experience. In: Kuerer HM, ed. Kuerer’s Breast Surgical Oncology. New York, NY: McGraw-Hill Companies; 2010:475-508.

4. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227-1232.

5. Fisher B, Dignam J, Wolmark N, Mamounas E, Costantino J, Poller W, et al. Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol. 1998;16(2):441-452.

6. Curran D, van Dongen JP, Aaronson NK, Kiebert G, Fentiman IS, Mignolet F, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC Trial 10801. The European Organization for Research and Treatment of Cancer (EORTC), Breast Cancer Co-operative Group (BCCG). Eur J Cancer. 1998;34(3):307-314.