Breast Cancer - Partial or Complete Breast Removal?

Summarized by Robert W. Griffith, MD
November 4, 2002 (Reviewed: November 13, 2004)

Introduction

Complete removal of the breast has been a standard surgical approach for breast cancer for almost the last 100 years. It is known as radical, or total mastectomy. (Radical mastectomy goes further, involving removal of underlying muscle and lymph nodes, while 'total' mastectomy may or may not include removal of the lymph nodes in the axilla). About 30 years ago, surgeons started to use techniques that were not so destructive, and which became known as breast-conserving operations. Two popular types are 'quadrantectomy', in which a quarter of the breast is removed, with or without some axillary lymph nodes, and 'lumpectomy', where just the tumor and a surrounding cuff of normal breast tissue are removed. In the 1970s two important studies were begun, which compared the results of breast-conserving surgery with those of mastectomy. Results after 20 years' follow-up have just been published in the New England Journal of Medicine, and we summarize them here.

The first study

This study started in Milan, Italy, in 1973, comparing radical mastectomy with quadrantectomy. Women up to age 70 who had a breast tumor with a diameter less than 2 cm and no enlarged axillary lymph nodes were randomly treated by radical mastectomy or quadrantectomy; in the latter case, the axillary lymph nodes were removed, and the remaining breast tissue was irradiated. If the lymph nodes showed cancer cells (25% of cases), the patients had chemotherapy as well.

A total of 701 women enrolled in the study - 349 had radical mastectomies, and 352 had quadrantectomies. Their average age was 50 years.

After 20 years, more women in the quadrantectomy group had a recurrence of their cancer in the area of breast removal than in the radical mastectomy group (about 9% vs. 2%). However, there were no differences in the numbers of cancer recurrence in the other breast, in distant parts of the body, or fresh cancers of other organs.

The overall death rates during the next 20 years were the same for the quadrantectomy and radical mastectomy groups (about 41%). The average age of these women was approaching 70, and only about 25% of them in each group had died from their breast cancer.

The second study

This was a study done in numerous centers across the USA that started in 1976. It compared the results of lumpectomy alone, lumpectomy followed by irradiation of the remaining breast tissue, and total mastectomy. Over 2,000 women with breast tumors up to 4 cm in diameter were randomly assigned to one of these three treatments. They all had removal of their axillary nodes, and those with any 'positive' node received chemotherapy. Women who had lumpectomy and were found later to have had incomplete tumor removal (about 10%, found by pathology exam) then had a total mastectomy.

Over 1,800 of the women had their 20-year results analyzed. Recurrences in the breast area were reported in 14% of the lumpectomy plus irradiation group, compared with 39% in the lumpectomy-alone women. But again, there were no differences in the numbers of cancer recurrence in the other breast, in distant parts of the body, or fresh cancers of other organs.

The overall 20-year rates of death from all causes were very similar for all three groups - 53% for total mastectomy, and 54% for both lumpectomy alone and lumpectomy with irradiation. The death rate due to breast cancer for the whole collective was 40%.

Conclusions

These two important studies reveal nothing to suggest that mastectomy has any 20-year survival advantage over breast-conserving surgery (quadrantectomy or lumpectomy). Death rates ranging from 41% to 54% may seem alarming, but they shouldn't be - the average age of survivors at the end of the follow-up period was about 70.

The fact that there were no differences in the occurrence of cancer in the other breast in irradiated patients indicates that the dose of radiation used did not provoke cancer - something that had been of concern for some time.

An increased rate of local recurrence with breast-conserving surgery (as seen in both studies) has also been a concern in the past. However, as there was no difference in breast-cancer deaths after 20 years, it's clear that deaths were due to hidden clusters of cancer cells at distant places in the body, rather than to any difference in the extent of surgery.

Clearly, every woman with breast cancer should be fully informed of the possibility of having breast-conserving therapy, and whether it's a suitable option in her particular situation. This is not, at present, the case. In 1999, almost a third of women with breast cancer in one US city were only offered the option of total mastectomy at their first consultation. We must hope this state of affairs will change, based on the findings from these two studies.

Sources

• Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. U. Veronesi, N. Cascinelli, L. Mariani,  et al., N Engl J Med, 2002, vol. 347, pp. 1227--1232



• Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. B. Fisher, S. Anderson, J. Bryant,  et al., N Engl J Med, 2002, vol. 347, pp. 1233--1241

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