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To chop or not to chop. Tuesday, April 20, 2010 Breast Cancer Treatment Is Breast Conservation Treatment a Safe Alternative to a Mastectomy for Breast Cancer? by Dr. Tan Mona More Articles by Author Although a diagnosis of breast cancer is devastating news, a positive aspect is that effective treatment is available. Even better news is that if detected early, breast conserving treatment provides similar cure rates as a mastectomy (the removal of the breast).1 As surgery is pivotal in the treatment of breast cancer, a woman who has been diagnosed with the problem is often given the choice between breast conservation treatment, often termed ‘lumpectomy’ and a mastectomy. In my practice, I have often been asked which would be the safer alternative. The majority of women I see have the concept that mastectomy provides the best protection against recurrence and death from breast cancer. This is understandably an instinctive response. I wish, however, in this article to offer available data in support of breast conservation treatment (BCT) as this is the appropriate mode of therapy for the majority of cases. In medicine, there is a continual effort to make recommendations based on rigorous studies. Some of these may show evidence that contradicts what may appear on the surface to be logical and reasonable. The results of the studies on BCT is one such example. Allow me to delve a little into history of surgery for breast cancer. The radical mastectomy was the mainstay of treatment for breast cancer for the greater part of the twentieth century after it was described by a surgeon named Halsted in 1891.2 This procedure was unchallenged for 70 years. However, surgery did not reduce death from breast cancer significantly. In 1907, Halsted reported the results of his procedure. Only 2 of 44 patients with metastasis were alive 5 years after undergoing radical surgery.3 Contrast this with a report from the Middlesex Hospital in London. From 1805 to1933, women who were diagnosed with breast cancer did not receive any form of treatment, but were cared for in the hospital until their deaths. 18% of these women survived 5 years and 4% 10 years from the time of diagnosis. From this, it may be concluded that no treatment (conservative management) is superior to the Halsted mastectomy. Is it therefore reasonable to recommend such a deforming and debilitating surgery for ALL women with breast cancer? Unfortunately, for want of another effective way to remove the cancer, doctors continued to offer the radical mastectomy for more than 70 years. Thankfully, there were some that recognised this issue and ventured to offer a different operation from the ‘stalwart of breast cancer operations’. These included breast conserving surgery which was introduced in the late 1970’s and early 1980’s. Performing well-designed studies and making recommendations based on the results of these studies allows the present generation of doctors to avoid the mistakes of our predecessors. Two of these studies have demonstrated that 20-year survival of women who have been treated with breast cancer is the same regardless of whether a mastectomy or breast conservation has been performed.4,5 This means that surgical treatment makes little difference to a patient’s longevity. The stage of the disease (size of cancer, spread to lymph nodes or other parts of the body) is more significant in determining a patient’s likelihood of cure. Surgery is not the only component of breast cancer treatment. Other modalities of therapy include radiotherapy, chemotherapy and hormonal therapy. The ultimate objective is to minimise the risk of recurrence and long term remission. One question that is often asked: if breast conservation treatment results in equivalent survival rates as a mastectomy, why do women opt for the latter? There may be a few reasons. Firstly, is that having been the dominant operation for breast cancer for the most part of the last century, there is possibly a reluctance to accept anything less ‘complete’. It is easy to rationalise that complete removal of the breast rids a woman of the problem and it will not bother her again. As explained above, this is not necessarily so. Secondly, breast conserving surgery is challenging. In order to avoid breast deformity after surgery, there are certain preoperative considerations that need to be made and technical manoeuvres applied during the course of surgery.6 Surgeons who are not familiar with these would be less likely to offer breast conservation. Studies have shown that it took time for breast conservation to be widely accepted in North America.7 It is now accepted as the recommended procedure for early breast cancer in Canada.8 A mastectomy is still performed if this is the patient’s preference, or if there are other factors that make breast conservation unsuitable. In summary, breast conserving surgery is appropriate treatment for early breast cancer and provides equivalent survival rates to a mastectomy. For those who would like to research further into this topic, we have enclosed the references: References 1. Schwartz GF et al. Consensus Conference on Breast Conservation, Milan, Italy, April 28-May1, 2005. The Breast Journal 2006;12(4):398-407. 2. Frykberg ER, Bland KI. Evolution of Surgical Principles and Techniques for the Management of Breast Cancer. In: The Breast – Comprehensive Management of Benign and Malignant Disorders. Bland & Copeland (eds). Saunders, Missouri, 2004. 3. Beenken SW et al. History of the Therapy of Breast Cancer. In: The Breast – Comprehensive Management of Benign and Malignant Disorders. Bland & Copeland (eds). Saunders, Missouri, 2004. 4. Veronesi U et al. Twenty-year follow-up of a randomised study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med 2002;347(16):1227-1232. 5. Fisher B et al. Twenty-year follow-up of a fandomised trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347(16):1233-1241. 6. Anderson BO et al. Oncoplastic approaches to partial mastectomy: an overview of volume-displacement techniques. Lancet Oncol 2005;6:145-57. 7. Lazovich D et al. Breast conservation therapy in the United States following the 1990 National Institutes of Health Consensus Development Conference on the treatment of patients with early stage invasive breast carcinoma. Cancer 1999 Aug 15;86(4):628-37. 8. Scarth H et al. Clinical practice guidelines for the careand treatment of breast cancer: Mastectomy or lumpectomy? The choice of operation for clinical stages I & II breast cancer. CMAJ 2002;167(2):154-5. | |