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Mastectomy No Better Than Breast-Conserving Surgeries

20-year survival rates are virtually identical

WEDNESDAY, Oct. 16, 2002 (HealthDayNews) -- Evidence keeps pouring in to support the belief that less surgery is better when it comes to breast cancer.

Two studies appearing in tomorrow's issue of The New England Journal of Medicine report that two different breast-conserving surgeries have the same 20-year survival rates as the previous gold standard, the radical mastectomy.

"This confirms what we've known for some time, that breast conservation is equivalent to mastectomy in terms of survival," says Dr. Carina Biggs, director of the breast center at Maimonides Medical Center in Brooklyn, N.Y.

Dr. Jay Brooks, chief of hematology/oncology at the Ochsner Clinic Foundation in New Orleans, says, "With the 20-year data, whether a woman decides to preserve her breast or keep it, the chances of being alive and free of cancer 20 years from now is the same."

Mastectomy is a perfectly fine operation to do if that is what a woman wants," he adds. "It's a personal decision."

The first study, led by Dr. Umberto Veronesi of the European Institute of Oncology in Milan, Italy, looked at 701 women who were randomly assigned to one of two groups: those receiving a radical mastectomy, and those receiving a procedure known as a quadrantectomy, in which the quadrant of the breast containing the tumor is removed.

Although the rate of local recurrence (when the tumor reappeared in the same breast) was higher in women who underwent a quadrantectomy, there was little difference in the incidence of metastasis -- or spread -- of the cancer. As a result, the overall survival rate was virtually identical among women in the two groups, the researchers say.

Veronesi says the study was the first randomized trial of mastectomy versus breast conservation.

"Now, after more than 20 years, the long-term follow-up of 701 women shows without any doubt that the curability rates after breast-conservation surgery are identical to that of the mastectomy patients," he says. "I believe that today the treatment of a woman with early breast cancer with mastectomy must be considered unethical."

The second study, conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) in Pittsburgh, was also a 20-year follow-up. It compared a radical mastectomy with a lumpectomy (removing the tumor and a margin of tissue), with and without radiation. This study is known as trial B-06.

Among 1,851 women randomly assigned to one of three treatment groups (total mastectomy, lumpectomy alone or lumpectomy with radiation), those receiving lumpectomy with breast irradiation had the lowest incidence of a recurrence in the same breast.

"That did not impact survival because when the cancer came back locally they underwent a mastectomy," Brooks explains.

The authors of the Pittsburgh study say it's unclear which of the two breast-conserving surgeries is better. The lumpectomy removed tumors that were four centimeters or less in diameter, while the quadrantectomy excised tumors that were two centimeters or less in diameter.

Brooks believes the lumpectomy is the better of the two options because "it gives a better cosmetic result."

In either case, the authors of the Italian study believe that about 300,000 women worldwide each year with early breast cancer will undergo breast-conserving surgery, rather than radical mastectomy, as a result of these two trials.

"The failure to observe a survival advantage of mastectomy after 20 years should convince even the most determined skeptics that mastectomy is not superior to breast-conservation for the treatment of breast cancer," Dr. Monica Morrow, of the Northwestern University Feinberg School of Medicine in Chicago, writes in an accompanying editorial.

The 25-year follow-up results of an earlier study, the NSABP's landmark B-04 trial, were published in August 2002. This study found no survival difference between radical mastectomies and simple mastectomies, in which lymph nodes and muscles are left in place.

The B-04 study, which was launched in 1972, has been hailed as the one that launched the trend toward less surgery for breast cancer patients.

The B-06 trial and its Italian counterpart are also pivotal studies.

"The B-06 is a tremendous, tremendous study," Brooks says. "Over the last 20 years we have revolutionized the way women with breast cancer are treated. The reason we know so much about breast cancer today is because of the courage of women in the past to participate in research trials."

The B-06 trial, which was the sixth study conducted by the NSABP, began in 1976.

This week, Brooks enrolled a patient in the B-34 trial, which is looking at whether a particular medication prevents metastasis of breast cancer to the bone.

What To Do

For more information on breast cancer, visit the National Cancer Institute or the Susan G. Komen Breast Cancer Foundation.

SOURCES: Carina Biggs, M.D., director, breast center, Maimonides Medical Center, Brooklyn, N.Y.; Jay Brooks, M.D., chief, hematology/oncology, Ochsner Clinic Foundation, New Orleans; Oct. 17, 2002, The New England Journal of Medicine
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