TREATMENT OF EARLY BREAST CANCER
Abstract
The early follow-up of patients treated by simple mastectomy alone or simple mastectomy combined with radical radiotherapy is presented. Both groups were well matched for age, menopausal status, duration of symptoms, size of tumour, and lymph-node involvement. There was no significant difference in survival of patients in the two groups at three years, but local recurrence was significantly more frequent (28%) in the mastectomy-alone patients. Early survival was not adversely affected by radiotherapy.
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Cited by (29)
Age disparities in triple-negative breast cancer treatment and outcomes: An NCDB analysis
2022, Surgery (United States)Citation Excerpt :Importantly, in our study, no survival benefit was observed in patients ≤40 years who underwent bilateral mastectomy. More extensive axillary surgery did not improve survival outcomes in any age group, consistent with evidence from multiple clinical trials demonstrating that ALND does not impact survival.23–26 These results are particularly important for the youngest group of TNBC patients, in whom more extensive surgical procedures were most commonly performed, perhaps unnecessarily.
Race, access to care, and molecular features result in outcome disparities in triple-negative breast cancer (TNBC). We sought to determine the role of age in TNBC disparity by hypothesizing that younger patients receive more comprehensive treatment, resulting in survival differences.
The National Cancer Database was used to identify women with unilateral TNBC treated from 2005 through 2017. Patients were stratified by age (≤40, 41–70, >70); demographics, clinical characteristics, and treatment factors were compared. Logistic regression determined factors associated with treatment received. Survival outcomes were analyzed using a stratified log-rank test.
Of the 168,715 patients, 16,287 (9.6%) were ≤40 years. Patients ≤40 were significantly more likely to present at higher clinical stage (P < .001) and receive neoadjuvant chemotherapy (NAC, P < .001). Bilateral mastectomy was the most common surgery for patients ≤40 (37%), whereas partial mastectomy was most often used in patients 41 to 70 years old (48%) and those >70 (49%) (P < .001). Patients ≤40 years were significantly more likely to undergo both NAC and mastectomy than those >40 (odds ratio 1.5, both P < .05) despite a greater in-breast tumor response in the youngest patients. Patients treated with mastectomy and axillary lymph node dissection had inferior survival outcomes compared to those treated with partial mastectomy and sentinel lymph node biopsy across all 3 age groups (P < .001).
The clinical characteristics of TNBC differ significantly at the extremes of age, likely driving treatment decisions. Although patients ≤40 present with a more advanced disease and appropriately receive NAC, they also undergo more extensive surgery that does not yield a survival benefit. Further research is needed to determine if age disparity is due to oncologic factors or patient and provider preferences.
De-escalating axillary surgery in early-stage breast cancer
2022, BreastCitation Excerpt :It has long been recognized that axillary surgery does not impact survival. This was first demonstrated in the landmark NSABP B-04 and Kings/Cambridge trials where patients with operable breast cancer and clinically negative axillae (cN0) were randomized to variations of axillary management [1,2]. Notably, in both trials, axillary treatment (surgery or radiation) did not impact overall survival yet did contribute substantially to local control.
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013–08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
Modified radical mastectomy and simple mastectomy
2018, The Breast: Comprehensive Management of Benign and Malignant DiseasesIntroduction: The surgical techniques used in mastectomy are in constant evolution because of advancement in knowledge and the needs of patients.
Methodology: Literature review of different types of mastectomy.
Results: Halsted radical mastectomy (RM), the first effective surgery in treating breast cancer, was later modified by Patey, Madden, and others to preserve the pectoralis major muscle. Studies showed comparable survival outcomes between the two types of mastectomy. The modified radical mastectomy (MRM) became the standard treatment for women with stage I and II breast cancer in the 1970s. However, the axillary lymph node dissection (ALND), a part of modified radical mastectomy, was associated with significant side effects. Hence, the simple mastectomy (SM) was developed to spare the ALND and focus on treating the local disease only. Studies showed that survival after SM with or without radiation was comparable to those with RM.
Recently, adjuvant systemic treatment has been shown to significantly improve disease-free and overall survival in patients with node-positive breast cancer, which requires nodal staging to guide therapy. Sentinel lymph node biopsy (SLNB) was invented to provide adequate pathologic nodal status in clinically negative axilla. Today, SM coupled with SLNB has largely replaced the MRM.
Additional modifications to mastectomy by sparing the skin and the nipple areolar complex further increased its popularity.
Discussion: The evolution of surgical treatment of breast cancer is governed by the principles of controlling the local disease and providing adequate pathology with minimal adverse effects. The validity of any new procedure requires confirmation.
The use of RT as a component of breast-conserving therapy or after mastectomy has been proven to reduce the risk of local-regional recurrence (LRR) and to improve long-term breast cancer-specific and overall survival. As has been the common practice in the United States and Continental Europe, the majority of studies that demonstrated these benefits utilized daily radiation doses ranging from 1.8-2 Gray (Gy). However, due to geographic limitations, patient preferences and financial considerations, there have been continued attempts to evaluate the efficacy and toxicity of abbreviated courses of breast RT. Two key factors in these attempts have been: (1) advances in radiobiology allowing for a more precise estimation of equivalent dosing; and (2) advances in the delivery of RT that have resulted in substantially improved dose homogeneity in the target volume. As an alternative to approximately five weeks of daily treatment at 1.8-2 Gy, delivering radiobiologically-equivalent total doses in hypofractionated, abbreviated schedules has been evaluated in five randomized controlled trials, as well as many prospective and retrospective experiences. These studies have generally demonstrated equivalent rates of LRR, disease-free survival and overall survival with the use of hypofractionated regimens. Despite theoretical and historic concerns that hypofractionated regimens could increase damage to normal tissue, the rates of acute and long-term toxicities have generally not been increased in most recent series. Some toxicities, however, may take years to decades to manifest.
Questions still remain regarding which patients are appropriate for abbreviated treatment. The majority of patients included in the studies supporting hypofractionated treatment were of older age with early-stage invasive ER+ disease of predominantly lower histological grade. This favorable subset of patients is also the most eligible for other alternative treatment approaches, such as partial-breast irradiation or hormonal therapy alone. Additionally, few to none of the patients included in most studies were treated with mastectomy, lymph node irradiation, a lumpectomy cavity radiation boost, or adjuvant chemotherapy.
The existing evidence prompted the American Society for Radiation Oncology (ASTRO) to convene a task force to issue an evidence-based guideline in 2010 delineating the patients for whom an abbreviated radiation course is most supported by the current evidence [Smith et al. 2010, Int J Radiat Oncol Biol Phys]. Ongoing and future studies will further clarify the suitability of a hypofractionated treatment approach for the patient subgroups underrepresented in available trials. Additionally, alternative abbreviated treatment regimens, including those in which treatment is given once weekly and treatments that include an integrated lumpectomy cavity boost, are actively being investigated. Finally, innovative radiation techniques, such as the use of higher energies, prone treatment, and breathing-adapted therapy have further increased the homogeneity of breast irradiation and minimized dose delivered to nearby critical normal structures. Consequently, increasing experience with these techniques may expand the population of patients amenable to hypofractionated therapy.
Modified Radical Mastectomy and Total (Simple) Mastectomy
2009, The Breast: Comprehensive Management of Benign and Malignant DiseasesLocoregional post-mastectomy radiotherapy for breast cancer: Literature review
2000, Cancer/RadiotherapieLa radiothérapie locorégionale délivrée après mastectomie et curage ganglionnaire est controversée. La récente parution des résultats de plusieurs essais randomisés a rendu caduque les conclusions de méta-analyses antérieures. L'analyse des essais randomisés qui ont comparé une irradiation postopératoire et l'absence de radiothérapie a montré une diminution du taux de rechute locorégionale secondaire à la radiothérapie et parfois montré une augmentation du taux de survie sans récidive, mais il n'a jamais été noté d'amélioration du taux de survie globale. Un grand nombre d'essais a comparé une irradiation postopératoire, un traitement systémique et l'association des deux traitements. Le taux de rechute locorégionale est statistiquement plus faible avec une irradiation ou l'association d'un traitement systémique et d'une radiothérapie qu'avec un traitement systémique seul. Il a été noté, dans ces nombreux essais, une amélioration du taux de survie sans récidive, voire de survie globale dans les groupes de patients recevant une radiothérapie. Ces améliorations des taux de survie ne sont envisageables que dans le cadre d'une radiothérapie bien conduite, épargnant au maximum le parenchyme pulmonaire et le muscle cardiaque. Par ailleurs, de nombreuses études rétrospectives ont souligné la difficulté à traiter à visée curative les rechutes locorégionales et le risque potentiellement accru de dissémination métastatique après une rechute locorégionale. Ces arguments conduisent à proposer une irradiation associée à un traitement systémique après une mastectomie, chez ces patientes qui ont un risque de rechute locorégionale important, en particulier en cas d'atteinte ganglionnaire et/ou de diamètre tumoral supérieur ou égal à cinq centimètres. La radiothérapie postopératoire n'est cependant pas sans conséquence sur les tissus sains, et l'observation de certaines règles d'irradiation peut permettre de diminuer les effets non désirés de l'irradiation.
Postoperative radiotherapy is controversial after radical mastectomy. Recent clinical trials have shown an increase in survival with this irradiation and conclusions of previous meta-analyses should be reconsidered. The results of a large number of randomized clinical trials in which women received post-mastectomy radiotherapy or not have been reviewed. These trials showed a decrease in locoregional failure with the use of postoperative radiotherapy but survival advantages have not been clearly identified. A larger number of randomized clinical trials compared postoperative radiotherapy alone, chemotherapy alone and the association of the two treatments. They showed that chemotherapy was less active locally than radiotherapy and that radiotherapy and chemotherapy significantly increased both disease-free and overall survival rates in the groups which received postoperative radiotherapy. These favourable results were, however, obtained with optimal radiotherapy techniques and a relative sparing of lung tissue and cardiac muscle. Many retrospective clinical analyses concluded that results obtained in locoregional failure rate were poor and that these failures led to an increase in future risks. Both radiotherapy and systemic treatment should be delivered after mastectomy, reserved for patients with a high risk of locoregional relapses, particularly of nodes and/or tumors with a diameter ≥5 cm. However, radiotherapy could produce secondary effects, and techniques of radiotherapy should be optimal. CD 2000 Editions scientifiques et médicales Elsevier SAS