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Breast Cancer
Major Site Report – Breast Cancer
Lumpectomy vs Mastectomy for Early Stage Invasive Breast
Cancer
For women with a choice in early breast cancer treatment, lumpectomy plus radiation therapy
(lumpectomy + RT) is considered as effective as mastectomy.
What are the differences between lumpectomy and mastectomy?
Type of surgery
Lumpectomy is the surgical removal of the tumor and some of the normal tissue surrounding it (not the
entire breast). This surgery removes less tissue than mastectomy and can leave the breast looking as
close as possible to the way it did before surgery. Most often, the shape of the breast and the nipple
area are preserved.
After a lumpectomy, a pathologist checks the tumor margins (the normal tissue surrounding the tumor)
to make sure all the cancer has been removed. When the margins contain no cancer cells (negative
margins), the lumpectomy is successful. However, if the margins contain cancer cells, more surgery
must be done. In these cases, a lumpectomy may no longer be an option and a mastectomy may be
needed.
Mastectomy is the surgical removal of the entire breast. In a total (simple) mastectomy, the surgeon
removes the breast, but no other tissue or lymph nodes. In a modified radical mastectomy, the surgeon
removes the breast, the lining of the chest muscles and some of the lymph nodes in the armpit. Breast
reconstruction may be done at the same time as the mastectomy or at a later date.
Radiation therapy (RT)
Radiation therapy to the breast is standard after a lumpectomy. It gets rid of any cancer cells that may
remain after surgery. This lowers the chances of the cancer returning.
In contrast, most women do not need radiation therapy after a mastectomy.
Chemotherapy and hormone therapy
Having lumpectomy + RT or mastectomy does not affect whether or not a woman’s treatment will also
include chemotherapy or hormone therapy. These choices are related to the characteristics of the
tumor rather than the type of surgery.
Risk of lymphedema
Lymphedema is a condition where lymph fluid collects in the arm, hand, finger or chest causing
swelling. The risk of lymphedema is the same whether a woman chooses lumpectomy + RT or
mastectomy. Women who have a large number of lymph nodes in the armpit removed during either
type of breast surgery or who have radiation to these lymph nodes are more likely to develop
lymphedema.1
When is lumpectomy + RT an option?
Not all women are candidates for lumpectomy + RT. In some cases, the location or size of the tumor
make mastectomy a better option than lumpectomy. These include:2
•
•
•
•
•
Two or more tumors in different areas of the breast (multi-centric tumors)
A large tumor, relative to breast size (for some women neoadjuvant therapy may reduce the
size of the tumor enough so that lumpectomy is possible)
A tumor spread throughout the breast (diffuse tumor)
Attempts at lumpectomy cannot get negative margins
Inflammatory breast cancer
Women treated with lumpectomy must have radiation therapy. Therefore, those who cannot have
radiation therapy due to certain health conditions may need to have a mastectomy instead. These
conditions include:2
•
•
•
Scleroderma or systemic lupus
Past radiation therapy to the same breast
Pregnancy (radiation therapy is not given during pregnancy, but women can have a
lumpectomy during pregnancy and have radiation therapy after delivery)
Lumpectomy + RT versus mastectomy in treating early breast
cancer
Overall survival
Findings from randomized controlled trials, meta-analyses and pooled analyses show there is no
difference in overall survival between women with early breast cancer treated with lumpectomy + RT
and those treated with mastectomy.3-9 Details of these studies are presented in Table 37 in the research
section.
Local and distant recurrence
The chance of the cancer returning in the breast (called local recurrence) is slightly higher with
lumpectomy + RT than mastectomy.4,6,8,9 However, the risk of cancer spreading to other organs (called
distant recurrence or metastasis and the main cause of breast cancer death), is the same for lumpectomy
+ RT and mastectomy.3,4,6
Summary of risks and benefits: lumpectomy + RT versus
mastectomy
There are risks and benefits to consider when choosing between lumpectomy + RT and mastectomy.
The main benefit of lumpectomy + RT is that the breast is preserved as much as possible.
The main benefit of mastectomy is that radiation therapy may not be needed. This can be an important
factor for women who live far from a radiation treatment center. And, although lumpectomy + RT and
mastectomy are equally effective in treating early breast cancer, for some women, mastectomy offers
more peace of mind.
Mastectomy
Amount of tissue removed
Extent of surgery
Hospital stay
Radiation therapy
Chance of local recurrence
Entire breast
Major surgery with general
anesthesia
Overnight hospital stay may be
needed
Longer recovery time than with
lumpectomy + RT
Sometimes done
Low
Lumpectomy + RT
Part of breast (preserves the look
of the breast as much as
possible)
Less extensive surgery with
general anesthesia
Often go home on same day as
surgery
Routinely done
Low (but slightly higher than
with mastectomy)
According to Dr. Terry Mamounas, Professor of Surgery, Northeastern Ohio Universities College of
Medicine and Medical Director, Aultman Cancer Center, Canton, OH, “Currently most women with
early-stage breast cancer are candidates for lumpectomy and radiation therapy. This approach
preserves the breast and provides the same overall survival to that achieved with total mastectomy.
Advances in imaging and surgical techniques, radiation therapy and adjuvant systemic therapy have
resulted in significant reduction in the rates of local recurrence after lumpectomy, making this
procedure the preferred method of surgical management for the majority of patients with early-stage
breast cancer.”
References
1. McLaughlin SA, Cohen S, Van Zee KJ. Chapter 45: Lymphedema, in Harris JR, Lippman ME,
Morrow M, Osborne CK. Diseases of the Breast, 4th edition. Lippincott Williams and Wilkins, 2010.
2. Kaufmann M, Morrow M, von Minckwitz G, Harris JR; Biedenkopf Expert Panel Members.
Locoregional treatment of primary breast cancer: consensus recommendations from an International
Expert Panel. Cancer. 116(5):1184-91, 2010.
3. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N.
Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 347(16):123341, 2002.
4. van Dongen JA, Voogd AC, Fentiman IS, et al. Long-term results of a randomized trial comparing
breast-conserving therapy with mastectomy: European Organization for Research and Treatment of
Cancer 10801 trial. J Natl Cancer Inst. 92(14):1143-50, 2000.
5. Blichert-Toft M, Nielsen M, Düring M, et al. Long-term results of breast conserving surgery vs.
mastectomy for early stage invasive breast cancer: 20-year follow-up of the Danish randomized
DBCG-82TM protocol. Acta Oncol. 47(4):672-81, 2008.
6. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing
breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med.
347(16):1227-32, 2002.
7. Early Breast Cancer Trialists' Collaborative Group. Effects of Radiotherapy and Surgery in Early
Breast Cancer. An Overview of the Randomized Trials. N Engl J Med. 333:1444-55, 1995.
8. Jatoi I, Proschan MA. Randomized trials of breast-conserving therapy versus mastectomy for
primary breast cancer: A pooled analysis of updated results. Am J Clin Oncol. 28(3):289-94, 2005.
9. van der Hage JA, Putter H, Bonnema J, et al. on behalf of the EORTC Breast Cancer Group. Impact
of locoregional treatment on the early-stage breast cancer patients: a retrospective analysis. Eur J
Cancer. 39(15):2192-9, 2003.
10. Morrow M, Jagsi R, Alderman AK, et al. Surgeon recommendations and receipt of mastectomy for
treatment of breast cancer. JAMA. 302(14):1551-6, 2009.
11. Habermann EB, Abbott A, Parsons HM, Virnig BA, Al-Refaie WB, Tuttle TM. Are mastectomy
rates really increasing in the United States? J Clin Oncol. 28(21):3437-41, 2010.
12. Alderman AK, Bynum J, Sutherland J, Birkmeyer N, Collins ED, Birkmeyer J. Surgical treatment
of breast cancer among the elderly in the United States. Cancer. 2010 Sep 30. [Epub ahead of print].
Rhonda Ballew, RN
Coordinator Oncology Research/
CC Data Management
Mastectomy versus Lumpectomy plus Radiation and
Overall Survival in Early Stage Breast Cancer
This summary table contains detailed information about research studies. Summary tables offer an
informative look at the science behind many breast cancer guidelines and recommendations.
Introduction: For women who have the option, lumpectomy (also called breast conserving surgery) plus
radiation therapy is just as effective as mastectomy for treating early breast cancer. The randomized controlled
trials, pooled analyses and meta-analyses in the table below show there is no difference in overall survival
between women treated with either method.
Study selection criteria: Randomized clinical trials with at least 150 participants and at least 10 years of followup, pooled analyses and meta-analyses.
Study
Study
Population
(number of
participants)
Stage of
Follow-up
Breast
(years)
Cancer
Overall Survival
(for length of follow-up)
Mastectomy
Lumpectomy
plus Radiation
Randomized clinical trials
NSABP B06 [1]
1,851
Stage I-II
21
47%
46%NS
EORTC [2]
868
Stage I-II
22
45%
39%NS
Danish
Breast
Cancer
Cooperative
Group [3]
731
Stage I-III
20
58%
51%NS
Milan [4]
701
Stage I
20
58%
59%NS
National
Cancer
Institute [5]
237
Stage I-II
26
44%
38%NS
Arriagada
[6]
179
Stage I
22
52%
60%*NS
Pooled and meta-analyses
71%NS
EBCTCG
[7]
4,891
Stage I-II
10
Jatoi et al.
[8]
4,061
Stage I-II
15
NS
NS
van der
Hage et al.
[9]
3,648
Stage III/III
11
68%
72%
71%
NS = No statistically significant difference between the two groups
References
1. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, Jeong JH, Wolmark N.
Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and
lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 347(16):123341, 2002.
2. Litière S, Werutsky G, Fentiman IS, et al. Breast conserving therapy versus mastectomy for stage III breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol.
13(4):412-9, 2012.
3. Blichert-Toft M, Nielsen M, Düring M, et al. Long-term results of breast conserving surgery vs.
mastectomy for early stage invasive breast cancer: 20-year follow-up of the Danish randomized
DBCG-82TM protocol. Acta Oncol. 47(4):672-81, 2008.
4. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a randomized study comparing
breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med.
347(16):1227-32, 2002.
5. Simone NL, Dan T, Shih J, et al. Twenty-five year results of the national cancer institute
randomized breast conservation trial. Breast Cancer Res Treat. 132(1):197-203, 2012.
6. Arriagada R, Le MG, Guinebretiere JM, Dunant A, Rochard F, Tursz T. Late local recurrences in a
randomised trial comparing conservative treatment with total mastectomy in early breast cancer
patients. Ann Oncol. 14(11):1617-22, 2003.
7. Early Breast Cancer Trialists' Collaborative Group. Effects of Radiotherapy and Surgery in Early
Breast Cancer. An Overview of the Randomized Trials. N Engl J Med. 333:1444-55, 1995.
8. Jatoi I, Proschan MA. Randomized trials of breast-conserving therapy versus mastectomy for
primary breast cancer: A pooled analysis of updated results. Am J Clin Oncol. 28(3):289-94, 2005.
9. van der Hage JA, Putter H, Bonnema J, et al. on behalf of the EORTC Breast Cancer Group. Impact
of locoregional treatment on the early-stage breast cancer patients: a retrospective analysis. Eur J
Cancer. 39(15):2192-9, 2003.
Rhonda Ballew, RN
Coordinator Oncology Research/
CC Data Management
Lumpectomy vs Mastectomy Study - Stage 0, I, II Breast Cancer Patients (2012)
Patient Sampling - Ananlytic Cases 205 - 188 Cases Identified for Review
Patients had Lumpectomy
Patients with lumpectomy who went on to mastectomy
Patients having Mastectomy only
*Patients who had surgery elsewhere or no surgery
105
12
71
188
17
205
*Surgery elsewhere - 13 patients
*No surgery - 4
A) One patient presented with three primaries, patient expired prior to surgical treatment.
B) One refused surgery
C) Two were aged 84/87 with multiple comorbidities
Results:
NAPBC guidelines state at least 50% of women diagnosed with early stage (0-II) breast cancer
should be treated with breast conservation therapy (lumpectomy + radiation therapy).
Based on 2012 analytic data AnMed Health has a 56% lumpectomy rate, well above the NAPBC recommendations.
Rhonda Ballew RN
21-Oct-13
By %
Lumpectomy vs Mastectomy Rate - Dx/Tx at AnMed vs Tx Elswhr
2012 Analytic Total Breast Cases
Stage 0-2
205
Page #s
1
2
3
4
5
6
7
8
9
10
11
12
13
Lumpectomy
8
7
9
8
5
10
8
8
13
8
10
10
1
*Mastectomy
1
1
0
2
2
0
0
2
0
1
3
0
0
Total
105
51.2%
12
5.9%
Total Surgeries
Lumpectomies
Lumpectomy Rate
Mastecomies
Mastectomy Rate
Mastectomy
Only
5
6
8
5
6
6
7
3
6
8
5
6
0
Surgery
Elswhere
0
1
1
2
1
1
1
3
0
2
0
1
0
No
Surgery
0
0
0
0
1
1
1
1
0
0
0
0
0
Number of
Patients
14
15
18
17
15
18
17
17
19
19
18
17
1
71
34.6%
13
6.3%
4
2.0%
205
100%
% Lump to
Mastec
11.4%
188
105
56%
83
44%
*Mastectomy: Lumpectomy first, then went on to have Mastectomy
** NAPBC recommends 50% lumpectomy or better
Source: CC Data Mmgnt 10, 2013
Page 1
CROSS-TABULATION OF SITE CODE BY CANCER DIRECTED SURGERY HERE FOR 10-LUMP-VS-MASTEC-DX-TX-RHONDA-B
SITE COD LUMPECTOMY
NBR
(%)
BREAST
105
MASTECTOMY
NBR
(%)
51.2
83
ALL OTHERS
NBR
(%)
40.5
17
DEPENDANT VARIABLES
LUMPECTOMY is CANCER DIRECTED SURGERY HERE 20-24
MASTECTOMY is CANCER DIRECTED SURGERY HERE 30-80
TOTAL VALUES
NBR
(%)
8.3
205
100
Evaluation and Treatment Planning Study – 2014
Breast Cancer Diagnostic Evaluation per NCCN Guidelines:
First course of treatment concordant with NCCN recommendations
Physician Review – CoC Standard 4.6
A sample selection of 20 analytic invasive breast cancer cases were identified by
the registry department and provided for review. Each case was evaluated for the
following items according to current NCCN guidelines;
•
•
•
•
•
Family history documented
Appropriate lab evaluation (CBC, platelet, LFT’s)
Bilateral diagnostic mammogram
Determination of ER, PR & HER2/neu for invasion
First course of treatment
After careful review the following findings were observed and documented for
physician review;
•
•
•
•
•
100% of the cases reviewed had family history documented
100% of the cases reviewed had the recommended lab evaluations
performed and documented
19 of 20 cases reviewed (95%) had ER, PR, HER2/neu determination
performed. The lone case for which this was not done had insufficient
material at biopsy to perform the test and no residual neoplasia in the
surgical specimen. 100% of eligible cases had the testing performed.
100% of the cases reviewed has first course of therapy concordant with
NCCN guidelines based on the results of the diagnostic workup.
25% of the patients underwent bilateral diagnostic mammogram as
recommended by NCCN guidelines. (In lieu of this finding, after physician
review and presentation to the QI committee, it was felt further investigation
was needed to determine the reasoning behind the difference in diagnostic
workup here and the recommended evaluation by NCCN).
Post review findings: Upon diagnosis of invasive breast cancer AnMed Health
patients undergo a unilateral diagnostic mammogram and ultrasound then proceed
straight to MRI for preoperative staging and surgical planning. The NCCN guidelines
lists in its most recent literature that “MRI is optional and may be used for staging
evaluation to define extent of cancer or presence of multifocal or multicentric
cancer in the ipsilateral breast, or as screening of the contralateral breast at time of
diagnosis”. It was felt by the radiologists that preoperative MRI was more effective
for staging the extent of the disease and helped provide useful information in
determining suitability for breast conservative surgery vs mastectomy.
Rhonda Ballew, RN
October 2014
MRI IN THE PREOPERATIVE EVALUATION: THE DEBATE
Numerous reports have shown that MRI can detect additional foci of breast cancer in a
substantial number of women with a new diagnosis of breast cancer. While some argue that
detecting these additional lesions should improve outcomes after the first operation and,
hopefully, lead to lower rates of recurrence, the long-term consequences of MRI-directed
changes in treatment have not been fully studied. Below is a summary of the arguments
both against and for the use of breast MRI in staging.
•
The argument against preoperative MRI
Mastectomy was the routine treatment for breast cancer into the 1980s. The arrival of
breast conservation surgery combined with radiation therapy offered major advantages with
similarly low recurrence rates. Based on the results of controlled clinical trials with mortality
as the end point, breast conservation therapy and mastectomy confer equivalent risk to the
patient. Any increase in the rate of mastectomy prompted by MRI findings would represent
a setback in the standard of care. And since radiation therapy is presumed to eradicate or
delay progression of residual disease in most women who undergo conservation therapy,
preoperative MRI would have little or no impact on rates of recurrence or death. Thus, MRI
should not be used routinely in the workup of new breast cancers.
•
The argument for preoperative MRI
The upper threshold amount of residual disease that can be eradicated by radiation therapy
is not yet well established. There are as yet no MRI criteria for assessing the likelihood of
standard treatment failure in individual patients with multifocal or multicentric disease, or
with occult cancer in the contralateral breast. Although the rate of recurrence after breast
conservation is low, it is not zero, and each patient should be offered the best possible
chance for successful treatment. Detecting widespread disease can obviate inappropriate
attempts at conservation, in which both lumpectomy with positive margins and re-excision
with positive margins are carried out before the full extent of the disease burden is
understood. Knowledge of the extent of disease at presentation will help the patient to
make a more informed decision when presented with treatment options. A staging MRI
examination showing only a single cancer lesion may permit the patient to choose
conservation therapy with a high degree of confidence that no macroscopic disease will be
missed at surgery.
•
Challenges for future clinical trials
These issues will not be easy to resolve. Definitive answers can only come from controlled
clinical trials with mortality as the end point, but for the data from these trials to be useful,
the trials must use standardized MRI technique and interpretation criteria. Such
standardization has yet to be accomplished.
In the absence of such guidance, it seems reasonable to use MRI for staging within the
known limitations of the technique and with secure histologic confirmation whenever
widespread disease is suspected from the MRI findings. In this way, the patient and her
surgeon can select a treatment plan based on the most realistic assessment of disease
burden.
References1.Comstock CE, Eby PR: 2nd Annual Great Debate: The Role of Breast MRI in
Preoperative Staging. American Roentgen Ray Society Annual Meeting.Presented May 4,
2014.
2. Medscape Education Radiology:Breast Cancer Imaging: MRI’s Role in Current Practice:
Gillian Newstead, MD 11/27/2012
Utility of Magnetic Resonance Imaging in the Management of Breast Cancer:
Evidence for Improved Preoperative Staging
1. Laura Esserman,
2. Nola Hylton,
3. Leila Yassa,
4. John Barclay,
5. Steven Frankel and
6. Edward Sickles
From the Departments of Surgery, Radiology, and Epidemiology and Biostatistics, University
of California, San Francisco, San Francisco, CA 94143.
Abstract
PURPOSE: The staging and treatment for breast cancer are changing; there is an increase in
the incidence of ductal carcinoma-in-situ, the use of fine-needle aspiration and stereotactic
biopsy for diagnosis, and the use of neoadjuvant chemotherapy. Thus, there is a need for a
tool to assess more precisely the extent of cancer in the breast before surgery. To better
plan surgical and chemotherapeutic interventions, we evaluated high-resolution magnetic
resonance imaging (MRI) as such a tool.
PATIENTS AND METHODS: Fifty-seven patients with 58 cases of breast cancer were
evaluated preoperatively with MRI using a technique called the triple-acquisition rapid
gradient echo technique to maximize anatomic detail. Imaging results were compared with
mammography and subsequent pathology results.
RESULTS: Magnetic resonance imaging correctly identified residual or primary cancer in 55
of 58 cases and accurately predicted the extent of the cancer in 54 of 58 cases. The
anatomic extent was more accurately defined with MRI compared with mammography (98%
v 55%). Magnetic resonance imaging added the greatest value in cases of multifocal
disease.
CONCLUSION: By applying MRI selectively to patients with a known diagnosis of cancer and
focusing on defining the extent of malignant lesions, we were able to obtain clear and
accurate anatomic information. Our results suggest that MRI could provide very valuable
information for preoperative planning and single-stage resection in breast cancer. Based on
preliminary data from our series, MRI would be valuable as a staging tool in the
preoperative setting even if the cost is in the range of $1,300 to $2,000. It is already
significantly less than the target cost, so it is reasonable to refine this technique for clinical
use to help plan the most appropriate surgical intervention and possibly reduce costs as
well. A careful prospective study is warranted to validate our findings.
Received March 19, 1997.Accepted September 1, 1998.
In Summary:
MRI FOR BREAST CANCER STAGING
MRI is effective for staging the extent of disease following a biopsy diagnosis of cancer. In
numerous studies, MRI has been shown to be superior to mammography and ultrasound for
estimating tumor size when compared with histopathology. In a comparison of
mammography, ultrasound and MRI using concordance with histopathology as the end
point, Essermanet al32 found that MRI showed the greatest improvement over
mammography and ultrasound for staging disease extent when multifocal disease or ductal
carcinoma-in-situ (DCIS) was present. Information about the extent of disease is useful in
determining suitability for breast conservative surgery and can be used to help guide breast
conservation. However, in practice, it is difficult to translate the anatomic boundaries of the
enhancing lesion seen on MRI to surgical coordinates with enough precision to ensure
adequate margins while minimizing the amount of tissue excised. A criticism of MRI is that it
is likely to result in more aggressive surgical approaches without necessarily improving
outcomes. Occult multifocality suggested by MRI should be verified by biopsy before
recommending substantial alteration to the surgical plan.
Boetes C, Mus RD, Holland R, et al: Breast tumors: Comparative accuracy of MR imaging
relative to mammography and US for demonstrating extent. Radiology 197:743-747, 1995
Soderstrom CE, Harms SE, Copit DS, et al: Three-dimensional RODEO breast MR imaging of
lesions containing ductal carcinoma in situ. Radiology 201:427-432, 1996
Esserman L, Hylton N, Yassa L, et al: Utility of magnetic resonance imaging in the
management of breast cancer: Evidence for improved preoperative staging. J ClinOncol
17:110-119, 1999