Inr. .I. Radiation
0
Oncology
Biol.
Phys..
1977. Vol.
2. pp. 369-370.
Pergamon
Press.
Printed
in the U.S.A.
Editorial THE PLACE OF RADIATION IN THE DEFINITIVE MANAGEMENT OF CARCINOMA OF THE BREAST SAMUEL
HELLMAN,
M.D.
Professor & Chairman, Department of Radiation Therapy, Harvard Medical School, Joint Center for Radiation Therapy, 50 Binney Street, Boston, MA 02115, U.S.A. Breast cancer, Radiation
therapy, Mastectomy,
One of the unexpected benefits of the recent reports concerning the use of adjuvant chemotherapy in breast cancer’.’ has been a general reconsideration of the treatment of this disease. In this issue Jean Spitalier and his colleagues report the results of using primary radiation therapy to treat 400 patients with Their results are quite mammary cancer.’ impressive. The 5-year disease free survival of 85% for Stage I and of 71% for Stage II are at least as good as those reported by surgery. It is important to remember that the incidence of local recurrence with traditional surgical treatment is high and this can be significantly reduced by postoperative radiation.““” There is considerable recent data suggesting that results similar to those obtained by combined radiation and mastectomy are attainable without such extensive surgery.3m8.1” The paper reported here, as well as our own,’ indicate the importance of tumor excision in the management of this disease. Local control figures can be significantly improved by gross removal of the tumor which does not require large surgical resections and is quite compatible with good cosmesis. This theme is consistent with the growing awareness of radiotherapists. High doses of radiation are necessary when gross tumor is present; these doses of radiation are sometimes associated with unacceptable cosmetic and functional impairment. However, gross removal of tumor allows more modest doses of radiation consistent with improved function and cosmesis. 369
Cesium therapy.
The concern for the cosmetic results is evident and documented in this study. Cosmetic results can be quite good since megavoltage treatment, and in this instance cesium treatment, allow relatively low doses to skin and subcutaneous tissues. Treatment of these superficial tissues in most cases is unnecessary unless is clinical there evidence of skin involvement. This is in marked contrast to the need for the treatment of superficial tissues following mastectomy. Boost therapy also seems important, and can be done, as in electrons or with this case, with cesium, interstitial implantation. We are most familiar with this latter technique and like the current study feel that the cosmetic results are excellent. Lastly, the authors point out that even those patients for whom this therapy fails are not lost since patients who have had mastectomy for recurrent tumor still have a 50% five year survival. Therefore, most patients can avoid mastectomy with good function and cosmetic results while those in whom such treatment fails can frequently be salvaged by mastectomy. It is important that other institutions gain experience using these techniques. However, I would urge that we profit from those who have experience in this matter and do not overtreat with external beam, but use bolus sparingly, rely on boost therapy and recommend excision of gross tumor. Perhaps such treatment will give us local control with a minimum mutilation of the patient. This
370
Radiation
Oncology
0 Biology 0 Phy\ica
treatment may then be considered within the context of the current investigations of the
March-April
1977. Volume
2. No.
3 and No. 4
utility of chemotherapy for the treatment subclinical micrometastases.
of
REFERENCES I. Bonadonna. G., Brusamolino, E.. Valagussa. P., Rossi. A., Brugnatelli, L., Brambilla. C.. De Lena, M.. Tancini, G., Bajetta, E., Musumeci. R., Veronesi. U.: Combination chemotherapy as an adjuvant treatment in operable breast cancer. N. Engl. J. Med. 294: 405-410, 1976. 2. Fisher, B.. Carbone, P.. Economou, S.G.. Frelick. R., Glass. A.. Lerner. H.. Redmond, C.. Zelen. M., Band, P.. Katrych. D.L., Wolmark. N., Fisher. E.R.: t_-Phenylalanine Mustard (L-PAM) in the management of primary breast cancer. N. Engl. J. Med. 292: 117-122. 1975. 3. Levene. M.B.. Harris, J.R., Hellman. S.: Treatment of carcinoma of the breast by radiation therapy. Cancer in press. 4. Peters, M.V.: Cutting the “Gordon Knot” in early breast cancer. Ann. R. Co/l. Physic. Surg. Cnn. 8: 186-192, 1975. 5. Pierquin, B., Baillet, F.. Wilson. J.F.: Radiation therapy in the management of primary breast cancer. Am. J. Roentgenol. 127: 645-648, 1976. 6. Prosnitz. L.R., Goldenberg. I.S.: Radiation therapy as primary treatment for early stage carcinoma of the breast. Cancer 35: lS87-1596. 1975. 7. Prosnitz, L.R., Goldenberg. I.S.. Packard,
8.
9.
IO.
I I.
12.
R.A.. Levene, 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. Cuncer in press. Sarrazin. D.. Fontaine, F.. Mouriesse. M.: Donnees actuelles sur la radiotherapie du cancer du sein. BdI. Cancer 62: 373-390. 1975. Spitalier, J.M.. Amalric, R.. Brandone. H., Santamaria, F., Ayme, Y., Seigle, J.: Cesium therapy of breast cancer: A five year report on 400 consecutive patients. Int. J. Radiat. Oncol. Bid. Phys. 2: 231-235, 1977. Weber, E., Hellman. S.: Radiation as primary treatment for local control of breast carcinoma. .f. Am. Med. Assoc. 234: 608-61 I. 1975. Weichselbaum, R.R.. Marck, A., Hellman, S.: The role of postoperative irradiation in carcinema of the breast. Cancer 37: 2682-2690, 1976. Zimmerman, K.W., Montague. E.D., Fletcher, G.H.: Frequency, anatomical distribution and management of local recurrences after definitive therapy for breast cancer. Cancer 55: 67-74, 1966.
0
Oncology
Biol.
Phys..
1977. Vol.
2. pp. 369-370.
Pergamon
Press.
Printed
in the U.S.A.
Editorial THE PLACE OF RADIATION IN THE DEFINITIVE MANAGEMENT OF CARCINOMA OF THE BREAST SAMUEL
HELLMAN,
M.D.
Professor & Chairman, Department of Radiation Therapy, Harvard Medical School, Joint Center for Radiation Therapy, 50 Binney Street, Boston, MA 02115, U.S.A. Breast cancer, Radiation
therapy, Mastectomy,
One of the unexpected benefits of the recent reports concerning the use of adjuvant chemotherapy in breast cancer’.’ has been a general reconsideration of the treatment of this disease. In this issue Jean Spitalier and his colleagues report the results of using primary radiation therapy to treat 400 patients with Their results are quite mammary cancer.’ impressive. The 5-year disease free survival of 85% for Stage I and of 71% for Stage II are at least as good as those reported by surgery. It is important to remember that the incidence of local recurrence with traditional surgical treatment is high and this can be significantly reduced by postoperative radiation.““” There is considerable recent data suggesting that results similar to those obtained by combined radiation and mastectomy are attainable without such extensive surgery.3m8.1” The paper reported here, as well as our own,’ indicate the importance of tumor excision in the management of this disease. Local control figures can be significantly improved by gross removal of the tumor which does not require large surgical resections and is quite compatible with good cosmesis. This theme is consistent with the growing awareness of radiotherapists. High doses of radiation are necessary when gross tumor is present; these doses of radiation are sometimes associated with unacceptable cosmetic and functional impairment. However, gross removal of tumor allows more modest doses of radiation consistent with improved function and cosmesis. 369
Cesium therapy.
The concern for the cosmetic results is evident and documented in this study. Cosmetic results can be quite good since megavoltage treatment, and in this instance cesium treatment, allow relatively low doses to skin and subcutaneous tissues. Treatment of these superficial tissues in most cases is unnecessary unless is clinical there evidence of skin involvement. This is in marked contrast to the need for the treatment of superficial tissues following mastectomy. Boost therapy also seems important, and can be done, as in electrons or with this case, with cesium, interstitial implantation. We are most familiar with this latter technique and like the current study feel that the cosmetic results are excellent. Lastly, the authors point out that even those patients for whom this therapy fails are not lost since patients who have had mastectomy for recurrent tumor still have a 50% five year survival. Therefore, most patients can avoid mastectomy with good function and cosmetic results while those in whom such treatment fails can frequently be salvaged by mastectomy. It is important that other institutions gain experience using these techniques. However, I would urge that we profit from those who have experience in this matter and do not overtreat with external beam, but use bolus sparingly, rely on boost therapy and recommend excision of gross tumor. Perhaps such treatment will give us local control with a minimum mutilation of the patient. This
370
Radiation
Oncology
0 Biology 0 Phy\ica
treatment may then be considered within the context of the current investigations of the
March-April
1977. Volume
2. No.
3 and No. 4
utility of chemotherapy for the treatment subclinical micrometastases.
of
REFERENCES I. Bonadonna. G., Brusamolino, E.. Valagussa. P., Rossi. A., Brugnatelli, L., Brambilla. C.. De Lena, M.. Tancini, G., Bajetta, E., Musumeci. R., Veronesi. U.: Combination chemotherapy as an adjuvant treatment in operable breast cancer. N. Engl. J. Med. 294: 405-410, 1976. 2. Fisher, B.. Carbone, P.. Economou, S.G.. Frelick. R., Glass. A.. Lerner. H.. Redmond, C.. Zelen. M., Band, P.. Katrych. D.L., Wolmark. N., Fisher. E.R.: t_-Phenylalanine Mustard (L-PAM) in the management of primary breast cancer. N. Engl. J. Med. 292: 117-122. 1975. 3. Levene. M.B.. Harris, J.R., Hellman. S.: Treatment of carcinoma of the breast by radiation therapy. Cancer in press. 4. Peters, M.V.: Cutting the “Gordon Knot” in early breast cancer. Ann. R. Co/l. Physic. Surg. Cnn. 8: 186-192, 1975. 5. Pierquin, B., Baillet, F.. Wilson. J.F.: Radiation therapy in the management of primary breast cancer. Am. J. Roentgenol. 127: 645-648, 1976. 6. Prosnitz. L.R., Goldenberg. I.S.: Radiation therapy as primary treatment for early stage carcinoma of the breast. Cancer 35: lS87-1596. 1975. 7. Prosnitz, L.R., Goldenberg. I.S.. Packard,
8.
9.
IO.
I I.
12.
R.A.. Levene, 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. Cuncer in press. Sarrazin. D.. Fontaine, F.. Mouriesse. M.: Donnees actuelles sur la radiotherapie du cancer du sein. BdI. Cancer 62: 373-390. 1975. Spitalier, J.M.. Amalric, R.. Brandone. H., Santamaria, F., Ayme, Y., Seigle, J.: Cesium therapy of breast cancer: A five year report on 400 consecutive patients. Int. J. Radiat. Oncol. Bid. Phys. 2: 231-235, 1977. Weber, E., Hellman. S.: Radiation as primary treatment for local control of breast carcinoma. .f. Am. Med. Assoc. 234: 608-61 I. 1975. Weichselbaum, R.R.. Marck, A., Hellman, S.: The role of postoperative irradiation in carcinema of the breast. Cancer 37: 2682-2690, 1976. Zimmerman, K.W., Montague. E.D., Fletcher, G.H.: Frequency, anatomical distribution and management of local recurrences after definitive therapy for breast cancer. Cancer 55: 67-74, 1966.
