In looking at the costs of treatment, the biggest variable was that women younger than 65 years of age had higher treatment costs than older women. This is likely due to the fact that these women were most likely to receive chemotherapy in addition to surgery and radiation. At 6 months, mastectomy ($12,987) was cheaper than mastectomy with hormonal treatment or chemotherapy ($14,309), breast conservation plus radiation ($14,963), and breast conservation plus radiation and adjuvant hormonal treatment or chemotherapy ($15,779). At 1 year, the costs were roughly equal. Breast conservation cost was in great part from the use of radiation therapy, whereas in mastectomy it was due to higher inpatient costs. Adjuvant therapy significantly increased costs regardless of the surgery chosen. By 5 years, the final cost of mastectomy was higher than that of breast conservation; this was likely due to the added costs of reconstruction, which on average added $9600 and other complications from mastectomy (4). Although there are some differences in cost, these are not enough to justify advocating one form of surgical treatment over another.

The choice of which surgical option is best for the patient depends in part on patient preference, tumor characteristics, and the recommendations of the surgeon. Tumor characteristics such as extensive calcifications, multicentricity, ability to obtain clear margins, tumor size with respect to breast size, and contraindications to radiation therapy could all preclude or advise against an attempt at breast conservation. Patient choice is often influenced by the experience of friends or relatives, their perception of what is a better treatment, access to radiation therapy facilities, and how they perceive body image versus a fear of local recurrence. Often patients report that their physicians did not present both options to them (5). Morrow et al. reported a significant correlation between the use of mastectomy and poor prognostic factors such as nodal status and tumor grade, suggesting that some surgeons may view breast conservation as less aggressive (6,7). This rationale is not necessarily sound; if a patient has a poor prognosis, she is generally more likely to recur systemically rather than locally. Surgeon practice volume has been correlated with the use of breast conservation, suggesting that experience and therapeutic bias may influence the surgical options offered (8). Continuing physician education and encouraging the use of high-volume centers should continue to decrease this problem.

Tumor size can be decreased by giving preoperative chemotherapy. This gives patients who desire breast conservation an opportunity to have it. In the NSABP B-18 trial, preoperative
chemotherapy was shown to decrease tumor size and increase the chances of breast conservation, especially among patients with tumors greater than 5 cm (9). McIntosh et al. reported that in 173 women with large or locally advanced breast cancer who were treated with chemotherapy, 44 (or 25%) underwent breast conservation after preoperative chemotherapy (10). After a mean follow-up of 62 months, 1 (2.3%) of the 44 patients who underwent breast conservation developed a local recurrence, and 9 (7.4%) of 121 who had a mastectomy developed a local recurrence. Patients who had better responses to chemotherapy were offered breast conservation, so there was a selection bias in this study. However, the results demonstrate that with proper patient selection, patients can be offered breast conservation postchemotherapy (10). In 2006, the Milan group published their review of 309 women who were candidates for mastectomy and then underwent neoadjuvant chemotherapy. In this group, 195 patients ended up having breast conservation surgery and 114 a modified radical mastectomy. At a median follow-up of 41 months 13 (6.7%) patients treated with breast conservation had an ipsilateral tumor recurrence. Six (3.1%) patients had a regional relapse, 28 (14.4%) women had distant metastases, and 24 (12.3%) patients had positive margins or margins that were less than 1 mm on their final pathology report. These patients all received radiation. Cumulative incidence of distant metastases was similar in patients with positive and negative margins, and there was no difference in terms of overall survival (11).

A French study by Soucy et al. was aimed specifically at comparing surgical margin involvement in breast conservation between those receiving neoadjuvant treatment and those with primary surgical treatment. Risk factors for positive margins have been studied and include age, family history, large tumor size, nodal involvement, presence of lymphovascular invasion, extensive intraductal component, and ductal or lobular extension (13). The authors reported a rate of 21% positive margins in those who underwent neoadjuvant chemotherapy and an 18% rate in the non-neoadjuvant group. Factors related to positive margins included higher nodal stage and larger tumor size, presence of lobular carcinoma, and positive hormonal receptors. Preoperative chemotherapy did not affect margin status. The authors felt that an association between positive hormone receptor status and positive margins remained unexplained. Twenty percent of positive hormonal receptor tumors had positive margins versus 10% for negative hormonal receptor tumors. Hormone receptor–positive tumors respond less to chemotherapy, but this does not explain their higher rates of positive margins overall. Lobular carcinoma had a significantly higher rate of positive margins, 43% versus 16% in ductal carcinoma. Lobular carcinoma tends to be multicentric and bilateral and more difficult to assess on conventional mammography. It also has a lesser response to neoadjuvant chemotherapy, all of which contribute to the higher rates of positive margins. Therefore, the authors concluded that although regression patterns after neoadjuvant chemotherapy can be variable, breast conservation afterward yields no higher incidence of positive margins than primary surgical treatment of invasive breast cancer (13).