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 Importance of Radiation for Triple-Negative Breast Cancer

Radiation therapy, which is standard treatment for many breast cancers, may be especially important for triple-negative breast cancer.

Triple-negative breast cancer, by definition estrogen-receptor, progesterone-receptor and HER2 negative, does not have as many treatment options as other breast cancers. Hormonal therapy and Herceptin (trastuzumab) for HER2 positive cancer are not effective.

Two recent studies highlighted the importance of radiation for triple-negative breast cancer.

Lumpectomy plus radiation better than mastectomy alone

A July 20 study in the Journal of Clinical Oncology found that women with small, node-negative, triple-negative breast cancer treated with mastectomy alone had a "significant increased risk" of local-regional recurrence compared to women treated with lumpectomy (breast conserving surgery) plus radiation. The authors noted that future studies are warranted to investigate the benefit of radiation after mastectomy in triple-negative breast cancer.

After mastectomy, chemotherapy plus radiation better than chemotherapy alone

Almost on cue, an August 16 study in Radiotherapy and Oncology evaluated the benefit of radiation after mastectomy in triple-negative breast cancer. (Link may be found on the postmastectomy radiotherapy (PMRT) page of our website.)

For women with early-stage triple-negative breast cancer treated with a mastectomy, chemotherapy plus radiation was "more effective" than chemotherapy alone. Recurrence rates and overall survival rates were significantly better in the group treated with radiation.

In both studies, women with triple-negative breast cancer treated with radiation fared better than those not treated with radiation.

Triple-negative breast cancer is a special situation. At our LATESTBreastCancer.com website, subscribers may create a profile based on their personal diagnosis to see the latest breast cancer news and research applicable to them. Our goal is to make internet research more efficient, and less overwhelming, for women with breast cancer.

Lumpectomy for Large, Lobular Breast Tumors? Treatment before surgery may make it possible

Is lumpectomy an option for breast cancer patients with large lobular tumors? According to two new studies, shrinking the tumors with chemo or hormonal therapy before surgery may allow some women to opt for a lumpectomy instead of a mastectomy.

If lumpectomy ends up being an option, how do you know if it's right for you? MD Anderson has developed an index to predict recurrence after chemotherapy followed by lumpectomy. Today we'll share a recent study on its effectiveness.

Links to all studies and a ScienceDaily.com news story may be found on the breast conserving surgery (lumpectomy) page of the LATESTBreastCancer.com website.

Annals of Surgical Oncology: "Neoadjuvant Chemotherapy Increases the Rate of Breast Conservation in Lobular-Type Breast Cancer Patients"

A July Annals of Surgical Oncology study from Vienna evaluated whether neoadjuvant (before surgery) chemotherapy resulted in more lumpectomies for women with lobular breast cancer.

The study leader, Dr. Florian Fitzal was quoted by ScienceDaily.com,

"Up until now it had been the view that neoadjuvant chemotherapy hardly had any benefits in cases of lobular breast cancer due to the poor response rate of the cancer, however no one had yet examined the question of the breast preservation rate."

The study found that after neoadjuvant chemotherapy, 45% of the women originally scheduled for mastectomy were able to have breast conserving surgery instead.

In addition, there was no difference in local recurrence between lobular and ductal cancers treated with breast conserving surgery, or between lobular patients treated with lumpectomy or mastectomy.

Breast Cancer Research and Treatment: "Invasive lobular carcinoma: response to neoadjuvant letrozole therapy"

Femara (letrozole) is an aromatase inhibitor used to treat hormone receptor positive breast cancer in post-menopausal women. An August 26 study in Breast Cancer Research and Treatment examined the effectiveness of Femara alone as neoadjuvant therapy in women with "estrogen receptor rich" lobular breast cancer. Women were considered for treatment if they had large operable or locally advanced breast cancer or were unfit for surgery. There was no control group. All study participants received Femara.

After 3 months of Femara, the average reduction in tumor volume was 61%, measured by ultrasound. At the time of publication, 40 of 63 patients underwent surgery, 31 of those were breast conserving surgeries. 21 patients continued with Femara alone, and 19 remained controlled at a median of 2.8 years.

The authors concluded that there is a "high rate of response" to Femara in post-menopausal women with estrogen receptor rich invasive lobular carcinoma.

The Risk of Local Recurrence After Breast Conserving Therapy in Patients Receiving Neoadjuvant Chemotherapy

Even if neoadjuvant chemotherapy can reduce tumor size, is a lumpectomy the right choice for you?

MD Anderson has developed a prognostic index to evaluate the risk of recurrence for patients treated with breast conserving surgery after neoadjuvant chemotherapy. (Link to the original study.) A score from 0 to 4 is calculated based on four factors. For each factor, a zero or one is assigned. For example,

Solitary tumors = 0; Multifocal = 1
Tumors less than or equal to 2cm = 0; Greater than 2cm = 1.
Initial lymph node status of N0 or N1 = 0; N2 or N3 = 1
Lymphovascular space invasion = 1; No invasion = 0.

The numbers are totalled to reach the prognostic index score.

An August 26 Annals of Surgical Oncology study evaluated the index in 551 patients treated from 2001 to 2005 with chemo, surgery (mastectomy or lumpectomy) and radiation. (The study does not distinguish between lobular or ductal breast cancer.)

For patients with a prognostic index score of 0, 1 or 2, the 5-year local-regional recurrence (LRR) free survival rates were similar between women treated with mastectomy and lumpectomy. However, when the score was 3 or 4, the 5-year LRR-free survival was significantly lower for patients treated with lumpectomy (69%) compared to mastectomy (93%).

The authors concluded, "The prognostic index can be used to identify patients at high risk for LRR who may be considered for more extensive surgery or enrollment into clinical trials evaluating novel strategies for local-regional control."

In addition to the prognostic index score, MD Anderson publishes several prognostic calculators to aid in the neoadjuvant chemotherapy decision process. Individual treatment decisions are based on many factors. Tools such as the prognostic index and calculators are factors to be considered, but ultimate decisions are made between a patient and her doctor.

Today's summary only highlights the most recent research on breast conserving surgery and neoadjuvant therapy. Two-years worth of news and research on every breast cancer test and treatment option may be found on the treatment pages of the LATESTBreastCancer.com website. Subscribers may create a profile based on their personal diagnosis to personalize their research.

Breast Cancer News (8/4): Is it safe to delay treatment?

After a breast cancer diagnosis, there's a natural sense of urgency to start treatment immediately. How long is it safe to wait? Today, we'll look at three recent studies on treatment delays for women with early, node-negative breast cancer.

Short delays before surgery not associated with significant changes in tumor size

In April, an MD Anderson study in the Annals of Surgery evaluated whether delays before breast cancer surgery affected tumor size for 818 clinically node-negative women. The median time from imaging to surgery was 21 days. The median difference in tumor size from mammogram to surgery was 0 cm, and from ultrasound to surgery was .1 cm. The researchers concluded, "Modest time intervals from imaging to surgery are not significantly associated with change in tumor size; thus, patients may undergo preoperative work-up without experiencing significant disease progression."

Senior researcher Dr. Funda Meric-Bernstam told Reuters Health, "Clearly, rapid treatment is desireable. However, taking a few weeks to coordinate care is safe. It's very unlikely there will be tumor progression."

Two studies on delays between surgery and radiation

Also in April, a study in Clinical Breast Cancer evaluated how delays between breast conserving surgery and the start of radiation affect local recurrence rates. 387 women with node-negative, early breast cancer were divided into four groups based on how long after surgery radiotherapy started - less than 60 days after surgery, 61 to 120, 121 to 180 and more than 180 days later. Five years later, "a delay in administering radiotherapy after breast-conserving surgery was not associated with an increased risk of local relapse." The authors did, however, acknowledge conflicting results from other published studies and noted that "a larger evaluation of this issue is warranted."

A Korean study in the May/June issue of Tumori evaluated the local recurrence rates for two groups of women with node-negative breast cancer treated with breast conserving surgery. The first group started radiation therapy within 6 weeks of surgery. The second group started more than six weeks after surgery. The eight-year "local control," meaning no local recurrence, rates were 94.5% in the less than six week group and 92.7% in the more than six week group. For women less than 40 years old, starting radiotherapy within six weeks of surgery was associated with "a higher local control rate." There was no statistically significant difference for older women. Also, the interval between surgery and radiation "had no impact on overall and distant metastasis-free survival." The authors concluded, "Early radiotherapy within 6 weeks of breast-conserving surgery is associated with increased local control in patients with node-negative breast cancer not undergoing chemotherapy."

The topic for today's blog was inspired by a recent Twitter chat where a breast cancer survivor advised the newly diagnosed not to rush to treatment, but to take time to explore options and seek second opinions. Twitter can be another valuable resource for breast cancer patients and survivors. Currently, a group of survivors, patients and medical professionals participate in a weekly chat under the #bcsm (breast cancer social media) hashtag. Conversations take place on Mondays at 9pm Eastern/6pm Pacific time. Recent topics have included "Advice for the Newly Diagnosed," and "How Breast Cancer Affects Families." To learn more, search for #bcsm on Twitter. I tweet under the name @ann_latestbc. I hope to see you there.

At LATESTBreastCancer.com, we'll continue to add breast cancer research on delays in treatment to our website and database. The studies discussed today can be found on the radiation and breast conserving surgery pages of our website.