Mastectomy or Lumpectomy Plus Radiation: The Latest (and Longest) Study

Women with breast cancer have two surgical options - mastectomy or lumpectomy plus radiation, also known as breast conserving surgery or breast conservation therapy.

Both have pros and cons, but which is better in terms of survival and recurrence?

Today we'll share the latest (and longest) study, a 25 year follow-up of the National Cancer Institute (NCI) Breast Conservation Trial. A link to the full-text of the study, published online in Breast Cancer Research and Treatment on November 24, may be found on the Breast Conserving Surgery page of our website.

Background: Six studies found similar survival outcomes

Six major trials have compared survival rates of the two surgical options. To date, all have found lumpectomy plus radiation to be an "accepted alternative" to mastectomy with "similar survival outcomes." (Links to the various study abstracts may be found in the References section at the end of the current study.)

In addition, a meta-analysis of all six trials conducted by the Early Breast Cancer Trialist Group Collaboration "confirmed the noninferiority of breast conservation therapy compared with mastectomy," despite differences in eligibility criteria and treatment technique between trials.

The current study is one of the original six. It shares data from a 25.7 year median follow-up. It is a relatively small study, but the longest reported follow-up to date.

The NCI study design

Between 1979 and 1987, 247 women with breast tumors measuring 5cm or less were randomized to receive either lumpectomy plus radiation or a mastectomy. All women were treated with chemotherapy (Adriamycin (doxorubicin) and Cytoxan (cyclophosphamide)). After 1985, postmenopausal women with node-positive, estrogen-receptor positive breast cancer were also given tamoxifen for five years.

No difference in overall survival

Similar to the other five studies, the current NCI study demonstrated "no survival differences when comparing lumpectomy followed by whole breast irradiation versus mastectomy."

After 25 years, however, there was a "slight" survival advantage in the mastectomy group.

Predictors of decreased survival included patient age older than 50, left-sided tumors, tumor size greater than 2cm and more than 4 positive lymph nodes.

No difference in risk of metastasis

The study found "no significant difference in risk of distant metastasis" between the two arms.

High rate of recurrence in the same breast as the lumpectomy

Even though survival and metastasis rates were similar, the NCI study found a high rate of tumor recurrence in the breast treated with a lumpectomy. "More than 1 out of every 5 patients (22.3%)" in the lumpectomy group experienced a recurrence in the same breast requiring a salvage mastectomy.

The authors note that recent research suggests that same-breast recurrences may be a risk factor for decreased survival. However, in this study, even though 27 patients experienced a same-breast recurrence, there was no survival difference between the two groups.

There are several possible reasons why the rate of same-breast recurrence in this study may be greater than in the other studies.

First, the new tumor may actually be a new cancer, not a recurrence. In fact, there were 11 cancers in the opposite breast in the lumpectomy group and 15 in the mastectomy group, demonstrating that new cancers can develop over time.

In addition, the recurrence rate may be higher because this is a longer study. In fact, 3 of the recurrences occurred after a patient had been disease-free for 20 years.

Also, by design, the NCI study included women with larger tumors. The trials with lower same-breast recurrence rates included smaller-tumors and "more stringent margin evaluation." It may be that the patients in this study were already at a higher-risk of recurrence.

Long-term side effects of radiation therapy

As part of the discussion, the authors wondered if the long-term side effects of radiation might have affected survival in lumpectomy group.

A previous meta-analysis suggested "a 1.3% increase in non-breast cancer death in patients receiving radiotherapy after surgery." Although there were 5 more non-breast cancer deaths in the lumpectomy group, this trial was "not adequately powered to detect late differences in non-breast mortality."

However, left-sided cancer was "a significant predictor" of mortality. Radiation to the left-breast has been associated with cardiotoxicity in other studies. The NCI is currently conducting "extensive cardiac studies" of the 60 surviving patients in this trial.

The authors conclude that now that patients are living longer, minimizing treatment toxicity "has become a priority."

This is only the latest study on breast conserving surgery. For two-years of news and research on this and other treatment options, please visit our LATESTBreastCancer.com website. You may start exploring by clicking the Treatments tab.

As a final note, triple-negative breast cancer is a special situation. We discussed the latest research on mastectomies and lumpectomies plus radiation for triple-negative patients in our August 31 blog.

The Breast Cancer News Update: June 14

Today's breast cancer news addresses hypnosis, breast conserving surgery and radiation.

Hypnosis during breast cancer surgery

Most of the news and research on hypnosis for breast cancer relates to managing hot flashes or pain. This week, the Toronto Sun reported on a Belgian study about hypnosis during breast cancer surgery. Of the 78 women in the study, 18 received a local anaesthetic plus hypnosis. The rest were given a general anaesthetic. Although the women who were hypnotized spent "a few minutes more" in the operating room, the time spent in recovery and in the hospital were "greatly diminished." In addition, according to one of the researchers, local anaesthesia can "block the body's stress response to surgery and could therefore reduce the possible spread of metastasis." At the UCL Hospital in Brussels, a quarter of all breast cancer surgeries are performed under local anaesthetic with hypnosis.

Multiple re-excisions are a safe alternative to mastectomy

According to a study in the Annals of Surgical Oncology, multiple re-excisions to obtain clear margins after breast conserving surgery (lumpectomy) are a safe alternative to mastectomy. In the study, 70 of 3,737 lumpectomy patients over a 10 year period had more than one re-excision. Of those 70, 49 eventually achieved clear margins. All 49 also received radiation. At a median follow-up of 64 months, 1 of the 49 patients had a local recurrence and 1 had a distant recurrence. The authors concluded that there was "an acceptably low risk" of recurrence "when negative margins are ultimately achieved."

Whole breast radiation when no breast mass is detected

Sometimes, when there is axillary metastasis, breast cancer will be diagnosed even with no palpable, mammographic or sonographic evidence of a breast tumor. This is called an occult primary. A UK study published in the European Journal of Cancer concluded that an occult primary should be treated with breast conserving surgery plus whole breast radiation or mastectomy. Although patients who did not receive radiation after lumpectomy experienced worse 5 year local recurrence and relapse free survival rates, there was no difference in overall survival rates. Also, the study suggested that it is "not necessary to irradiate the breast to more than 50Gy in 25 fractions." Higher doses made no difference in local recurrence rates.

Please check back tomorrow for more breast cancer news from LATESTBreastCancer.com, the only place on the web where you may personalize your research to your diagnosis.

The Breast Cancer News Update: June 3

Today in breast cancer news, there are developments in imaging, prognostic testing and radiation therapy. Many of today's developments will be presented at the American Society of Clinical Oncology (ASCO) meeting this week.

Breast cancer imaging: screening, risk and impact on surgical decisions

The FDA considers mammography to be the most effective breast cancer screening method. According to a press release in PR Newswire, women should not substitute breast thermography for mammography for breast cancer screening. The FDA is "unaware of any valid scientific evidence" supporting thermography alone as a breast cancer screening method.

In addition to breast cancer detection, breast cancer risk may be assesed at a screening mammogram. According to a UCSF study published in Cancer Epidemiology, Biomarkers & Prevention, measurements of the volume of breast density at mammogram predict breast cancer risk more accurately than current risk models.

According to a study in the Journal of Surgical Oncology, the routine use of diagnostic MRI increases mastectomy rates. MRI is more sensitive to multifocal disease than mammography. MRI detection of multifocal disease is "highly correlated with pathology results," and appears to "justify the performance of mastectomies" in those circumstances.

Breast cancer prognostic testing: C-reactive protein, PAM50 and taxane response

A study in Denmark discovered that women who have high levels of C-reactive protein at diagnosis may have worse outcomes. However, researchers cautioned that their findings may be limited to the Danish population tested and that other known markers were not included in the study.

According to a Business Wire press release, several papers on the utility of the PAM50 assay will be presened at ASCO this week. The PAM50 test provides a subtype classification and prognostic score based on breast tumor biology.

Also, positive study results of a test to predict a patient's response to taxane therapy will be presented. The latest results corroborate an earlier study published in the May 11 issue of JAMA.

Breast cancer radiation: trends for women over 70 and therapy for liver metastases

Presentations on radiation therapy will also be made at ASCO this week.

Researchers Thomas Jefferson University will present data on radiation therapy use by women over 70 with stage I cancer. More women are choosing brachytherapy radioactive implants, such as MammoSite, Contura or Savi, and more women with estrogen positive tumors are opting out of radiation therapy. Researchers also discovered that women with estrogen negative tumors were 91 percent more likely to die from breast cancer if they did not receive radiation after lumpectomy, and that "radiation is currently being underutilized in these women."

For metastatic patients, an Italian study which concluded that SIR-Spheres radioactive microspheres for breast cancer liver metastases were "effective and well-tolerated" will also be presented.

Please check back on Monday for highlights of the weekend breast cancer news. Until then, all of the latest news and research on breast cancer tests and treatment options can be found on the LATESTBreastCancer.com website.

The Breast Cancer News Update: May 29

Happy Memorial Day from LATESTBreastCancer.com. We hope everyone is able to enjoy a day with family and friends. We honor those we have lost in service to our country and those we have lost to other battles.

The research world continues to fight breast cancer. Here are today's top breast cancer research developments.

Mepilex Lite dressings for skin reactions to radiation

For women undergoing radiation therapy for breast cancer, a recent randomised trial found that Mepilex Lite dressings significantly reduced the severity of radiation-induced skin reactions when compared to standard aqueous creams. The dressings reduced pain and discomfort and permitted women to wear normal clothing, thereby increasing quality of life.

Three breast conserving surgery (lumpectomy) studies

This weekend, we added three studies on breast conserving surgery to our database. All three were from the International Journal of Radiation Oncology, Biology, Physics and may be found on the breast conserving surgery (lumpectomy) page of our website.

The first, from The Netherlands, found that for patients under 40 with early-stage breast cancer, 10-year overall survival rates were "not impaired" after breast conserving surgery as compared to after mastectomy. In addition, patients with 1 to 3 positive nodes had a better prognosis after breast conserving surgery than after mastectomy.

Researchers from the Harvard Radiation Oncology Program found that women with basal and HER2 molecular subtypes of breast cancer had higher true recurrence rates than others after breast conserving surgery. They concluded that for basal cancers, strategies such as increased boost doses, concomitant radiation and chemotherapy, and/or targeted agents should be explored.

Finally, French researchers concluded that women who had previously received radiation therapy for Hodgkin's Lymphoma, were still candidates for breast conserving surgery plus radiation, with accommodations to protect heart and lung tissue.

More on cancer cell behavior from the biology labs

Medical News Today covered two discoveries in from the breast cancer biology labs.

The first revealed that in healthy cells, the p53 tumor suppressor can resist signals from defective growth factors and prevent improper cell division for 8 continuous hours. After 8 hours of signals from a growth factor, p53 releases "its grip on the cell's DNA, allowing it to divide." Cancerous cells lack or have defective p53. This understanding of differences between healthy and cancerous cells may lead to "new effective approaches to chemotherapy."

The second study revealed that cancer cells accelerate aging of nearby connective tissue, resulting in inflammation, which provides "fuel" for the tumor to grow or metastasize. This discovery may lead to future treatments involving anti-inflammatory and antioxidant products.

We'll continue to add developments in breast cancer research to our database and website, and highlight new discoveries here. Please stay tuned.