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Breast-conserving therapy plus radiation improved survival in patients with early-stage disease
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Patients with early-stage breast cancer treated with breast-conserving therapy plus radiation experienced improved survival compared with those who underwent mastectomy alone, according to results of a population-based study.
It has long been believed that mastectomy and breast-conserving therapy with radiation offer equivalent outcomes. Recent studies suggested more women are opting to undergo mastectomy, possibly due to improvements in reconstruction techniques or a more positive attitude toward the surgical treatment, according to background information in the study.
“In light of reports showing renewed interest in mastectomy, and because there have been few opportunities to observe long-term treatment-associated outcomes in the general population, we asked whether the comparable survival outcome of [breast-conserving therapy] compared with mastectomy as seen in randomized controlled trials could generalized to the non-clinical trial population,” E. Shelley Hwang, MD, MPH, of the division of surgical oncology at Duke University Medical Center, and colleagues wrote.
The researchers obtained data from the California Cancer Registry between 1990 and 2004. They analyzed 112,154 women diagnosed with stage I or II breast cancer who underwent lumpectomy plus radiation (55%) or mastectomy alone (45%). Researchers compared OS and disease-specific survival (DSS) between the two cohorts.
Median follow-up was 110.6 months.
A total of 31,416 deaths occurred in the cohort during the study period, including 39% due to breast cancer.
Women who underwent lumpectomy plus radiation experienced improved OS and DSS compared with women who underwent mastectomy (HR=0.81; 95% CI, 0.80-0.83), study results showed.
Women aged 50 years or older with hormone-sensitive tumors who were treated with breast-conserving treatment plus radiation were 13% less likely to die from breast cancer and 19% less likely to die from any cause compared with those who underwent mastectomy, researchers found.
Researchers observed a greater DSS benefit among women aged 50 years or older with HR-positive tumors treated with breast conserving therapy (HR=0.86; 95% CI, 0.82-0.91) compared with women aged 50 years or younger with HR-negative tumors (HR=0.88; 95% CI, 0.79-0.98).
“The hopeful message is that lumpectomy plus radiation was an effective alternative to mastectomy for early-stage disease, regardless of age or tumor type,” Hwang said in a press release. “Our study supports that even patients we thought might benefit less from localized treatment, like younger patients with hormone-resistant disease, can remain confident in lumpectomy as an equivalent and possibly better treatment option.”
Perspective
Back to TopDouglas Yee, MD
The increasing incidence of bilateral mastectomy in early-stage breast cancer has been well documented (Tuttle TM. J Clin Oncol. 2007;25:5203-5209), but evidence demonstrating improved outcomes for more aggressive surgery is lacking. In this registry study, Hwang and colleagues evaluated the outcomes of women who had mastectomy compared with women who received lumpectomy and radiation. It is notable that the authors excluded women who received post-mastectomy radiation and women who had lumpectomy without radiation, only evaluating patients who were treated in a similar manner as the randomized controlled studies.
The authors found that mastectomy was associated with inferior outcome compared with women who had breast-conserving therapy (BCT), both for OS and disease-specific survival. Although this is not a randomized clinical trial and is subject to many biases, these data support findings from the randomized trials that suggest BCT does not lead to inferior outcomes. Somewhat unexplained is the observation that BCT was superior to mastectomy.
A major limitation of this study was the lack of the description of systemic adjuvant chemotherapy and/or hormonal therapy. If there was an imbalance in the delivery of systemic therapy — patients with mastectomy mistakenly assume that this is all the therapy they need, for example — then this could account for the differences in long-term outcome. Also, by excluding women who had post-mastectomy radiotherapy (35% of the mastectomy group had positive lymph nodes and generally had larger tumors with no description of margins), this also could bias the mastectomy group to worse outcomes due to undertreatment of the axillae and chest wall. Despite these serious limitations, this study adds to the data necessary to talk with women about surgical choices, appropriate therapy and long-term outcomes.
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