Mastectomy
No Better Than Breast-Conserving Surgeries
20-year
survival rates are virtually identical
Evidence
keeps pouring in to support the belief that less surgery is better when
it comes to breast cancer.
Two
studies appearing in a recent issue of The New England Journal
of Medicine report that two different breast-conserving surgeries
have the same 20-year survival rates as the previous gold standard,
the radical mastectomy.
"This
confirms what we've known for some time, that breast
conservation is equivalent to mastectomy in terms of survival," says
Dr. Carina Biggs, director of the breast center at Maimonides Medical
Center in Brooklyn, N.Y.
Dr.
Jay Brooks, chief of hematology/oncology at the Ochsner Clinic Foundation
in New Orleans, says, "With the 20-year data, whether a woman decides
to preserve her breast or not keep it, the chances of being alive and
free of cancer 20 years from now is the same."
Mastectomy
- A Personal Decision
Mastectomy
is a perfectly fine operation to do if that is what a woman wants,"
he adds. "It's a personal decision."
The
first study, led by Dr. Umberto Veronesi of the European Institute of
Oncology in Milan, Italy, looked at 701 women who were randomly assigned
to one of two groups: those receiving a radical mastectomy, and those
receiving a procedure known as a quadrantectomy, in which the quadrant
of the breast containing the tumor is removed.
Although
the rate of local recurrence (when the tumor reappeared in the same
breast) was higher in women who underwent a quadrantectomy, there was
little difference in the incidence of metastasis—or spread—of
the cancer. As a result, the overall survival rate was virtually identical
among women in the two groups, the researchers say.
Veronesi
says the study was the first randomized trial of mastectomy versus breast
conservation.
"Now,
after more than 20 years, the long-term follow-up of 701 women shows
without any doubt that the curability rates after breast-conservation
surgery are identical to that of the mastectomy patients," he says.
"I believe that today the treatment of a woman with early breast cancer
with mastectomy must be considered unethical."
Radical
Mastectomy Compared With Lumpectomy
The
second study, conducted by the National Surgical Adjuvant Breast
and Bowel Project (NSABP) in Pittsburgh, was also a 20-year
follow-up. It compared a radical mastectomy with a lumpectomy (removing
the tumor and a margin of tissue), with and without radiation. This
study is known as trial B-06.
Among
1,851 women randomly assigned to one of three treatment groups (total
mastectomy, lumpectomy alone, or lumpectomy with radiation), those receiving
lumpectomy with breast irradiation had the lowest incidence of a recurrence
in the same breast.
"That
did not impact survival because when the cancer came back locally they
underwent a mastectomy," Brooks explains.
The
authors of the Pittsburgh study say it is unclear which of the
two breast-conserving surgeries is better. The lumpectomy removed tumors
that were four centimeters or less in diameter, while the quadrantectomy
excised tumors that were two centimeters or less in diameter.
Brooks
believes the lumpectomy is the better of the two options because "it
gives a better cosmetic result."
In
either case, the authors of the Italian study believe that about 300,000
women worldwide each year with early breast cancer will undergo breast-conserving
surgery, rather than radical mastectomy, as a result of these two trials.
"The
failure to observe a survival advantage of mastectomy after 20 years
should convince even the most determined skeptics that mastectomy is
not superior to breast-conservation for the treatment of breast cancer,"
Dr. Monica Morrow, of the Northwestern University Feinberg School of
Medicine in Chicago, writes in an accompanying editorial.
The
25-year follow-up results of an earlier study, the NSABP's
landmark B-04 trial, were published in August 2002. This study found
no survival difference between radical mastectomies and simple mastectomies,
in which lymph nodes and muscles are left in place.
The
B-04 study, which was launched in 1972, has been hailed as the one that
launched the trend toward less surgery for breast cancer patients.
The
B-06 trial and its Italian counterpart are also pivotal studies.
"The
B-06 is a tremendous, tremendous study," Brooks says. "Over the last
20 years we have revolutionized the way women with breast cancer are
treated. The reason we know so much about breast cancer today is because
of the courage of women in the past to participate in research trials."
The
B-06 trial, which was the sixth study conducted by the NSABP, began
in 1976.
This
week, Brooks enrolled a patient in the B-34 trial, which is looking
at whether a particular medication prevents metastasis of breast cancer
to the bone.
Treatment
choices for breast cancer should be made in collaboration with your
physician based on your individual medical history. Always consult your
physician for more information.
Online
Resources
American
Cancer Society
National
Alliance of Breast Cancer Organizations
National
Breast Cancer Coalition
National
Cancer Institute
National
Surgical Adjuvant Breast and Bowel Project (NSABP)
The
New England Journal of Medicine
Women's
Information Network Against Breast Cancer (WIN ABC)
|
November
2002
Breast
Conservation Equivalent to Mastectomy in Terms of Survival
Mastectomy
- A Personal Decision
Radical
Mastectomy Compared With Lumpectomy
More
Choices in Breast Cancer Treatment
Online
Resources
Find
a St. John's Mercy Physician
In
Other Breast Health News:
More
Choices in Breast Cancer Treatment
It
is now about patient involvement, experts say
Nearly
200,000 women and about 1,000 men are diagnosed with breast cancer
each year in the United States.
Unlike
the past, when a biopsy was often followed by immediate surgical removal
of the affected breast, most of today's newly diagnosed patients have
a range of treatment options to weigh, as well as a greater voice
in when these treatments are used.
Shelly
Blechman, vice president of the Women's Information Network
Against Breast Cancer (WIN ABC), says these options fall
into three broad categories:
-
Surgical
procedures such as biopsies, lumpectomies, and mastectomies to
establish the diagnosis, remove the local disease in the breast,
and estimate the extent of the disease.
-
Radiation
therapy to control local disease in the breast or other sites
where the cancer has spread.
-
Chemotherapy
or hormone therapy to treat the breast cancer, reduce the likelihood
of recurrence, and treat the known spread of the cancer to other
parts of the body.
"There
have been significant improvements in the past decade in the treatment
of breast cancer," Blechman says. "Not only are biopsies less invasive,
but there are a range of skin-sparing surgeries that can preserve
most of a breast, if the woman wants to do so, as well as advances
like sentinel node biopsies to identify whether cancer has spread."
"The
availability of these newer procedures provide women with a much greater
voice in the treatment process than they've ever had before," she
adds.
While
39,600 American women will die from the disease this year, breast
cancer death rates declined significantly from 1992 to 1996, with
the largest decrease in younger women—both Caucasian and African-American.
This decline is probably the result of earlier detection and improved
treatment, the American Cancer Society says.
Breast
cancer patients' participation in treatment decisions has been enhanced
by advances in breast cancer detection. In fact, the two go hand-in-hand,
according to most experts.
"The
majority of women diagnosed with breast cancer these days are in an
early stage of the disease," explains Dr. Jennifer Eng-Wong, a Cancer
Prevention Fellow at the National Cancer Institute.
"The
emphasis on annual screening means we are finding these cancers when
they are growing relatively slowly, and the prognosis is good. When
cancer is in Stage 0, I, or II, the patient still feels well," she
explains.
"Emergency
or next-day surgery is not necessary," she adds. "And there's time
for them to take part with their surgeon, oncologist, radiologist,
and others on their treatment team in reaching a thoughtful, reasoned
decision about how they want their cancer treated."
Eng-Wong
says it is not uncommon for women with early stage breast cancer to
take up to six weeks to decide how to proceed with treatment, with
no adverse effect on their health or treatment outcomes.
"Most
women seek all the information they can get during this period," she
says. "Many secure second or even third opinions about whether a lumpectomy,
mastectomy, radiation, or chemotherapy is best for them. And most
take the time to prepare themselves and their family members emotionally
for the treatment processes and its aftermath."
Although
it is still common for effective breast cancer therapy to involve
more than one form of treatment, how these treatments are combined
and timed is more and more often a matter for the medical team and
the patient to determine collaboratively.
Some
patients try a course of chemotherapy or radiation before surgery.
Others have a lumpectomy or mastectomy first, followed by radiation,
chemotherapy or both, Eng-Wong says.
She
notes that women with later stage breast cancer—Stage III or
IV —typically do not have as much time to gather information,
make a decision, and prepare themselves for the treatment and its
common side effects.
"When
breast cancer has reached Stage III or IV, there is definitely more
of an urgency to get the treatment under way," she says. "A delay
of a week or two between diagnosis and treatment is more common. Fortunately,
more and more American women are securing screening mammograms and
clinical breast exams on a regular basis. This helps to ensure that
when breast cancer does develop, it is detected promptly."
Always
consult your physician for more information.
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