Langenbecks Arch. Chir. 345 (KongreBbericht 1977)
Langenbeek~ Arc,hiv fi]r Chirurgie © by Springer-Verlag1977
16a. The Management of Early Cancer of the Breast W. D. George Department of Surgery, University of Liverpool, Liverpool L69 3BX, England
Management of Early Breast Cancer Summary. The results of clinical trials for early cancer of the breast were assessed in terms of survival, morbidity, and the rate of local recurrance. Simple mastectomy appeared to be the operation of choice because survival following this procedure was equal to that following more radical operations, but the morbidity was less. Partial mastectomy was found to be an unsatisfactory method of treatment. Simple mastectomy should be combined with removal of the lower axillary nodes to allow accurate staging of the disease. Postoperative radiotherapy did not influence survival, but did increase morbidity. It may be best to restrict its use to the treatment of local recurrance. Improvement in survival figures may be seen by use of adjuvant chemotherapy, or by more widespread use of screening programmes.
Key words: Mastectomy, s i m p l e - Radiotherapy, postoperative, restrictionChemotherapy, adjuvant.
The treatment of cancer which is apparently localised to the breast or local nodes still remains controversial. The operative procedures available range from extended radical mastectomy to simple excision of the lump. In addition any of these procedures may be combined with post operative radiotherapy. The basic question is whether any one form of local therapy is superior to the others. Many clinical trials have been carried out to answer this question and the results of these have been assessed by the following criteria. First and most important, survival, secondly the rate of local recurrance after treatment, and lastly the morbidity produced by treatment.
The Role of Post-operative Radiotherapy The role of post operative radiotherapy was assessed in two large trials carried out in the United Kingdom. Radical mastectomy and radiotherapy was compared with
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radical mastectomy without radiotherapy (Easson, 1968). No difference in survival was found at 10 years but there was a higher incidence of local recurrance in those patients who did not receive radiotherapy. The same pattern of results was found when simple mastectomy alone was compared with simple mastectomy and radiotherapy (C.R.C. Trial, 1976). These results suggest that the only benefit which results from post operative radiotherapy is a reduction in the rate of local recurrance. This benefit must be balanced against the increased morbidity, in terms of swelling of the arm, and stiffness of the shoulder, which may be produced by radiotherapy. If local recurrance does occur it can be treated adequately by radiotherapy at that time, and if radiotherapy is held in reserve in this way many patients will be spared the additional morbidity produced by such treatment.
Which Operation? It has been suggested that wide local excision of the tumor (partial mastectomy) is a satisfactory treatment for apparently early disease. This hypothesis was tested in a trial in which wide local excision was compared with radical mastectomy (Atkins et al., 1972). No difference in survival was found at 10 years in patients with Stage I disease but in Stage II disease the survival of women treated by partial mastectomy was significantly worse (P < 0.05) than that of those treated by radical mastectomy. In addition there was a higher rate of local recurrance in patients treated by partial mastectomy for both Stage I and Stage II disease. These results suggest that partial mastectomy is not an adequate form of treatment. At the other extreme is extended radical mastectomy which involves disection of the internal mammary, axillary, and supra clavicular nodes, in an attempt to eradicate surgically, all local disease. This procedure was compared with simple mastectomy in a clinical trial (Kaae and Johansen, 1968). No difference was found at 10 years in either the survival rate of the rate of local recurrance but extended radical mastectomy has a much higher rate of morbidity than the simple operation. Several trials have been carried out to compare radical and simple mastectomy (Brinkley and Haybittle, 1966; Burn, 1974; Hamilton et al., 1974). None of these have found any difference in survival between the two operations, but radical mastectomy has a higher morbidity than the simple operation. The results of all these trials suggest that simple mastectomy is the treatment of choice because it is as effective as more radical procedures and has a lower morbidity. Simple mastectomy does have one drawback in that it does not allow accurate staging of the axillary nodes, and consequently those patients with involved nodes, who have a bad prognosis, cannot be identified and considered for adjuvant therapy. Clinical staging cannot be relied upon to identify patients with involved nodes because false positive and false negative findings approaching 50% have been reported. For these reasons simple mastectomy should be combined with a careful disection of the axillary tail of the breast, a search for low axillary or pectoral nodes, and a meticulous pathological search of the excised specimen. In this way those patients with spread of disease to the axilla can be identified and considered for adjuvant therapy.
The Management of Early Cancer of the Breast
113
Discussion Although local treatment does improve survival over patients who receive no treatment at all the number of patients cured remains small. Brinkley and Haybittle (1975) have suggested a cure rate of only 18.5% in a series of patients followed for over 20 years. Most deaths occur from metastases which presumably are present at the time of initial treatment. The advent of bone scanning has shown that many patients with apparently early disease have asymptomatic bony metastases undetectable by conventional measures (Galasco, 1972) and this probably explains the relative failure of local treatment. Of the local treatments available simple mastectomy appears to be the treatment of choice but it should be combined with removal of the lower axillary nodes to allow accurate staging of the disease. Routine post operative radiotherapy does not confer any benefit in terms of survival but it does increase the morbidity. For these reasons it may be best to restrict its use to the treatment of local recurrance. It seems unlikely that further variations in local treatment will result in a reduction in mortality, and that such a reduction will only be achieved by a different approach to the disease process. The one factor which governs prognosis above all else is the stage of the disease at the time of diagnosis. If the disease is detected in its very early stages high rates of cure are achieved (Gallagher, 1971). This has led to the concept of screening normal women in the hope that the disease may be detected early and so hopefully be cured. The results of several studies suggest that screening can lead to a significant reduction in mortality (Shapiro et al., 1973) and that it is feasible to provide a screening service run by non-medical staff (George et al., 1976). In established disease a reduction in mortality may be achieved by the use of adjuvant chemotherapy to treat occult metastases. Encouraging early results have been reported using this form of treatment (Fisher, 1975; Bonadonna, 1976) but much longer follow up is required before the role of adjuvant chemotherapy can be assessed adequately.
References Atkins, H. et al.: Br. Med. J. 2, 423 (1972) Bonadonna, G., et al.: New Engl. J. Med. 294, 405 (1976) Brinkley, D., Haybittle, J. L.: Lancet 196611, 291 Brinkley, D., Haybittle, J. L.: Lancet 1975 I1, 95 Burn, J. I.: Br. J. Surg. 61, 762 (1974) Trial, C.R.C.: Br. Med. J. 1, 1035 (1976) Easson, E. C.: In: Prognostic factors in breast cancer, p. 118. London: Livingstone 1968 Fisher, B. et al.: New Engl. J. Med. 292, 117 (1975) Galasco, C. S. B.: Ann. Roy. Coll. Surg. Engl. 50, 3 (1972) Gallagher, H. S., Martin, J. E.: Cancer 28, 1505 (1971) George, W. D. et al.: Br. Med. J. 2, 858 (1976) Hamilton, T. et al.: Br. J. Surg. 61, 758 (1974) Kaae, A., Johansen, H.: In: Prognostic factors in breast cancer, p. 93. London: Livingstone 1968 Shapiro, S. et al.: Seventh National Cancer Conference, p. 663. Philadelphia: Lippincott 1973
Langenbeek~ Arc,hiv fi]r Chirurgie © by Springer-Verlag1977
16a. The Management of Early Cancer of the Breast W. D. George Department of Surgery, University of Liverpool, Liverpool L69 3BX, England
Management of Early Breast Cancer Summary. The results of clinical trials for early cancer of the breast were assessed in terms of survival, morbidity, and the rate of local recurrance. Simple mastectomy appeared to be the operation of choice because survival following this procedure was equal to that following more radical operations, but the morbidity was less. Partial mastectomy was found to be an unsatisfactory method of treatment. Simple mastectomy should be combined with removal of the lower axillary nodes to allow accurate staging of the disease. Postoperative radiotherapy did not influence survival, but did increase morbidity. It may be best to restrict its use to the treatment of local recurrance. Improvement in survival figures may be seen by use of adjuvant chemotherapy, or by more widespread use of screening programmes.
Key words: Mastectomy, s i m p l e - Radiotherapy, postoperative, restrictionChemotherapy, adjuvant.
The treatment of cancer which is apparently localised to the breast or local nodes still remains controversial. The operative procedures available range from extended radical mastectomy to simple excision of the lump. In addition any of these procedures may be combined with post operative radiotherapy. The basic question is whether any one form of local therapy is superior to the others. Many clinical trials have been carried out to answer this question and the results of these have been assessed by the following criteria. First and most important, survival, secondly the rate of local recurrance after treatment, and lastly the morbidity produced by treatment.
The Role of Post-operative Radiotherapy The role of post operative radiotherapy was assessed in two large trials carried out in the United Kingdom. Radical mastectomy and radiotherapy was compared with
112
W.D. George
radical mastectomy without radiotherapy (Easson, 1968). No difference in survival was found at 10 years but there was a higher incidence of local recurrance in those patients who did not receive radiotherapy. The same pattern of results was found when simple mastectomy alone was compared with simple mastectomy and radiotherapy (C.R.C. Trial, 1976). These results suggest that the only benefit which results from post operative radiotherapy is a reduction in the rate of local recurrance. This benefit must be balanced against the increased morbidity, in terms of swelling of the arm, and stiffness of the shoulder, which may be produced by radiotherapy. If local recurrance does occur it can be treated adequately by radiotherapy at that time, and if radiotherapy is held in reserve in this way many patients will be spared the additional morbidity produced by such treatment.
Which Operation? It has been suggested that wide local excision of the tumor (partial mastectomy) is a satisfactory treatment for apparently early disease. This hypothesis was tested in a trial in which wide local excision was compared with radical mastectomy (Atkins et al., 1972). No difference in survival was found at 10 years in patients with Stage I disease but in Stage II disease the survival of women treated by partial mastectomy was significantly worse (P < 0.05) than that of those treated by radical mastectomy. In addition there was a higher rate of local recurrance in patients treated by partial mastectomy for both Stage I and Stage II disease. These results suggest that partial mastectomy is not an adequate form of treatment. At the other extreme is extended radical mastectomy which involves disection of the internal mammary, axillary, and supra clavicular nodes, in an attempt to eradicate surgically, all local disease. This procedure was compared with simple mastectomy in a clinical trial (Kaae and Johansen, 1968). No difference was found at 10 years in either the survival rate of the rate of local recurrance but extended radical mastectomy has a much higher rate of morbidity than the simple operation. Several trials have been carried out to compare radical and simple mastectomy (Brinkley and Haybittle, 1966; Burn, 1974; Hamilton et al., 1974). None of these have found any difference in survival between the two operations, but radical mastectomy has a higher morbidity than the simple operation. The results of all these trials suggest that simple mastectomy is the treatment of choice because it is as effective as more radical procedures and has a lower morbidity. Simple mastectomy does have one drawback in that it does not allow accurate staging of the axillary nodes, and consequently those patients with involved nodes, who have a bad prognosis, cannot be identified and considered for adjuvant therapy. Clinical staging cannot be relied upon to identify patients with involved nodes because false positive and false negative findings approaching 50% have been reported. For these reasons simple mastectomy should be combined with a careful disection of the axillary tail of the breast, a search for low axillary or pectoral nodes, and a meticulous pathological search of the excised specimen. In this way those patients with spread of disease to the axilla can be identified and considered for adjuvant therapy.
The Management of Early Cancer of the Breast
113
Discussion Although local treatment does improve survival over patients who receive no treatment at all the number of patients cured remains small. Brinkley and Haybittle (1975) have suggested a cure rate of only 18.5% in a series of patients followed for over 20 years. Most deaths occur from metastases which presumably are present at the time of initial treatment. The advent of bone scanning has shown that many patients with apparently early disease have asymptomatic bony metastases undetectable by conventional measures (Galasco, 1972) and this probably explains the relative failure of local treatment. Of the local treatments available simple mastectomy appears to be the treatment of choice but it should be combined with removal of the lower axillary nodes to allow accurate staging of the disease. Routine post operative radiotherapy does not confer any benefit in terms of survival but it does increase the morbidity. For these reasons it may be best to restrict its use to the treatment of local recurrance. It seems unlikely that further variations in local treatment will result in a reduction in mortality, and that such a reduction will only be achieved by a different approach to the disease process. The one factor which governs prognosis above all else is the stage of the disease at the time of diagnosis. If the disease is detected in its very early stages high rates of cure are achieved (Gallagher, 1971). This has led to the concept of screening normal women in the hope that the disease may be detected early and so hopefully be cured. The results of several studies suggest that screening can lead to a significant reduction in mortality (Shapiro et al., 1973) and that it is feasible to provide a screening service run by non-medical staff (George et al., 1976). In established disease a reduction in mortality may be achieved by the use of adjuvant chemotherapy to treat occult metastases. Encouraging early results have been reported using this form of treatment (Fisher, 1975; Bonadonna, 1976) but much longer follow up is required before the role of adjuvant chemotherapy can be assessed adequately.
References Atkins, H. et al.: Br. Med. J. 2, 423 (1972) Bonadonna, G., et al.: New Engl. J. Med. 294, 405 (1976) Brinkley, D., Haybittle, J. L.: Lancet 196611, 291 Brinkley, D., Haybittle, J. L.: Lancet 1975 I1, 95 Burn, J. I.: Br. J. Surg. 61, 762 (1974) Trial, C.R.C.: Br. Med. J. 1, 1035 (1976) Easson, E. C.: In: Prognostic factors in breast cancer, p. 118. London: Livingstone 1968 Fisher, B. et al.: New Engl. J. Med. 292, 117 (1975) Galasco, C. S. B.: Ann. Roy. Coll. Surg. Engl. 50, 3 (1972) Gallagher, H. S., Martin, J. E.: Cancer 28, 1505 (1971) George, W. D. et al.: Br. Med. J. 2, 858 (1976) Hamilton, T. et al.: Br. J. Surg. 61, 758 (1974) Kaae, A., Johansen, H.: In: Prognostic factors in breast cancer, p. 93. London: Livingstone 1968 Shapiro, S. et al.: Seventh National Cancer Conference, p. 663. Philadelphia: Lippincott 1973
