Patient Selection for Breast-Conservation Therapy

Patient Selection for Breast-Conservation Therapy

Michele L. B. Ley

Jeffrey A. Sugandi

Breast-conservation therapy (BCT) has been accepted as an appropriate treatment modality for many patients with early-stage breast cancer. The term BCT encompasses breast-conserving surgery or lumpectomy followed by radiation therapy to treat any microscopic residual tumor. Prior to the advent of BCT, all breast cancer patients underwent mastectomy as a part of their treatment. With BCT, patients are able to preserve their breast without sacrificing oncologic outcomes. The goals of BCT are to provide minimal loss of breast tissue while achieving survival equivalency of mastectomy, and minimizing risks of breast cancer recurrence. The National Comprehensive Cancer Network continues to recognize BCT as being supported by the highest level of evidence (category 1) in terms of its equivalency to mastectomy for treatment of early breast cancer in majority of women with respect to overall survival (1).

From 1973 to 1980, recruitment of patients at the Milan Cancer Institute was designed to compare radical mastectomy to breast-conserving surgery “quadrantectomy.” The goal of the surgical technique was to remove the primary carcinoma and a generous amount of surrounding tissue, including skin and muscular fascia. Preliminary data published between 1977 and 1981 showed that survival rates were equal (2). Of the 701 women who entered the trial, 177 died of breast cancer—86 in the radical mastectomy group and 91 in the group that received breast-conserving therapy. Local recurrences were higher in the group that received breast conservation. The highest rate of recurrence was in women 45 years of age or younger. The 20-year follow-up study by Veronesi showed that the long-term survival of women with early breast cancer who were treated with breast-conserving surgery and postoperative radiotherapy to the breast was identical to women who underwent radical mastectomy (41.7% vs. 41.2%) (2).

Similarly, in 1971, the National Surgical Adjuvant Breast and Bowel Project (NSABP) initiated the B-04 study, a randomized clinical trial to resolve controversy over the surgical management of breast cancer. The 25-year follow-up showed there was no survival difference between the Halsted mastectomy and less extensive surgery—partial mastectomy (3).

The NSABP B-06 trial was then designed to evaluate breast-conserving surgery in women with stage 1 and 2 tumors that were less than 4 cm in size. Patients were randomized to lumpectomy alone, lumpectomy with radiation, or total mastectomy. In a 20-year follow-up study, no survival differences were noted among the three groups. The local recurrence rate in patients who underwent lumpectomy without radiation was 39.2% versus 14.3% in the group that received radiation (4). Therefore, in terms of survival, data has shown that breast-conserving surgery has a similar long-term outcomes compared to mastectomy. Table 6-1 summarizes the results of randomized prospective trials comparing mastectomy to BCT for invasive breast cancer.

Local recurrence is an important aspect of BCT due to its implications of risks of disease return, risks of increased mortality, as well as morbidity associated with retreatment. In the early trials, higher local recurrence rate for BCT was reported to be in the range of approximately 5% to 20%. With the advancement of current systemic therapy, local recurrences have been evaluated to be approximately 2% at 10 years (9).

Patient Selection for BCT

With the evidence of similar survival benefit, BCT has become an acceptable, attractive alternative to mastectomy for many patients with invasive breast cancer (Table 6-2).

However, not every patient is an appropriate candidate for BCT. In fact, careful patient selection with a multidisciplinary approach is essential to the success of BCT.

Patients diagnosed with invasive breast cancer should undergo thorough evaluation, including the different components as described below, in order to determine eligibility for this approach (15).

History and Physical

A complete history and physical examination can provide remarkable amount of information required to determine eligibility. Important elements that should be elucidated
in history includes the presence and characteristics of nipple discharge, palpable mass, symptoms suggestive of metastasis, date of last menstrual period, possibility of pregnancy, family history of breast cancer or ovarian cancer, history of prior radiation treatment, and history of prior cosmetic breast surgery.

TABLE 6-1 Comparison of Prospective Randomized Trials Mastectomy Versus BCT for Invasive Breast Cancer

Trial N Follow-up (yr) Inclusion Criteria (TNM) Local Recurrence (%) Overall Survival (%)
Mastectomy BCT + RT Mastectomy BCT + RT
Institute Gustave Roussy, France (5) 179 14.5 ≤2 cm, N0–1, M0 18 13 65 73
National Tumor Institute, Milan, Italy (2) 701 20 ≤2 cm, N0–1, M0 2.3 8.8 58.8 58.3
NSABP B-06 (4) 1,444 20 ≤2 cm, N0–1, M0 10.2 14.3 47 46
National Cancer Institute (6) 237 10 ≤5 cm, N0–1, M0 10 5 75 77
EORTC (7) 868 8 ≤5 cm, N0–1, M0 12.2 19.7 66 65
Danish Breast Cancer Group (8) 731 20 Any, N0–1, M0 6.9 4.5 50.6 57.8
TNM, tumor, nodes, metastasis; NSABP, National Surgical Adjuvant Breast and Bowel Project; EORTC, European Organization for Research and Treatment of Cancer.

During physical examination, it is important to note the presence of scars, implants, palpable mass, tumor size and location, skin or nipple retraction, skin involvement, ratio of tumor size to breast size, axillary and supraclavicular adenopathy, presence of multiple tumors, and evidence of inflammatory breast cancer such as peau d’orange and lymphedema of ipsilateral limb. It is important to note that nipple involvement, small area of skin involvement, and regional nodal disease are not considered absolute contraindications to breast-conserving surgery.

Radiologic Evaluation

Typical preoperative imaging workup should include a combination of diagnostic mammogram with appropriate magnifications, and ultrasound if indicated. The surgeon should review the imaging studies in order to determine the extent of patient’s disease, the presence or absence of multicentricity, and other factors that may influence treatment decisions such as lymph node appearance and the presence or absence and location (submuscular or subglandular) of implants. Bilateral breast imaging is important to evaluate the status of contralateral breast. If microcalcifications are present, their extent, location, and distribution should be noted. Ipsilateral disease multifocality and/or multicentricity may influence the eligibility of breast-conserving surgery as described below.

The routine use of magnetic resonance imaging (MRI) in patients with newly diagnosed breast cancer remains controversial. Although MRI may be useful as an adjunct for investigation of multifocal or multicentric disease, some patients may not benefit from the routine use of breast MRI. Fancellu et al. found that MRI in BCT candidate patients may increase the rate of mastectomy and did not significantly reduce reoperation rate for positive margins (16). MRI may be indicated in patients with dense breast tissue and who have evidence of multicentricity on mammography or on physical examination.

Patient Preferences Regarding Breast Conservation Versus Mastectomy

Patient’s choice is often influenced by the experience of friends or relatives, their perception of what is a better
treatment, access to radiation therapy facilities, as well as their body image and fear of local recurrence. Each patient and her surgeon must thoroughly discuss risk and benefits comparing mastectomy versus BCT. Topics of discussion must include expectations regarding treatment course, cosmetic outcome, long-term survival, the risks and possibility of recurrence, and the effect on patient’s psychological and perceived quality of life.

TABLE 6-2 Comparison of Prospective Randomized Trials of BCS With or Without RT for Invasive Breast Cancer

Trial N Follow-up (yr) Local Recurrence (%) Overall Survival (%)
NSABP B-06 (4) 1,137 20 39.2 14.3 46 46
National Tumor Institute, Milan Italy (10) 567 10 23.5 5.8 76.9 82.4
Ontario Clinical Oncology Group, Canada (11) 837 8 35 11 76 79
Uppsala Orebro Breast Cancer Group, Sweden (12) 381 10 24 8.5 78 77.5
Tampere-Helsinki, Finland (13) 263 12 27.2 11.6 79.8 84.8
NSABP B-21 (14) 668 8 16.5 2.8 94 93.4
NSABP, National Surgical Adjuvant Breast and Bowel Project.

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Aug 25, 2021 | Posted by in Aesthetic plastic surgery | Comments Off on Patient Selection for Breast-Conservation Therapy

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