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

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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

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.