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Evidence Based
For invasive breast cancer
 BCT is Tumor excision, axillary node
dissection, whole breast radiation
 Modified mastectomy is total
mastectomy and axillary node
dissection
 BCT = Modified Mastectomy, in both
Recurrence and OS
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Recurrence
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BCT 1-2%/yr - Recurrence is in-breast, 80 %
in primary treated field, 20% new primary or
regional
Post mastectomy - Recurrence is chest wall
The recurrences are different biologies, and
etiologies
The type of recurrence for BCT is eliminated
by mastectomy
The type of recurrence for mastectomy is
eliminated by radiation therapy
Recurrence
Since these recurrence “rates” are
approximately equal, the treatment
successes look the same.
 But if you add radiation to mastectomy
then there will be a gain in overall
survival, i.e. Mastectomy+Rad is
superior to BCT, most effect with node
positive. Gain of >5% at 15 years.
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Radiation
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Partial breast radiation
Eliminates treatment of “out of field” cancers
known to exist in 20-40%
Provides a shell of inadequate therapeutic
radiation ideal for induction of cancer.
It should fail to treat each of the distinct risk
issues unique to BCT and Mastectomy
Predicts an increase in late failures
Effect of radiotherapy after breast-conserving surgery
(10 trials of BCS  RT) on local recurrence and on breast cancer mortality
6097 women with node-negative disease
Effect of radiotherapy after breast-conserving surgery
(10 trials of BCS  RT) on local recurrence and on breast cancer mortality
1214 women with node-positive disease
Effect of radiotherapy after mastectomy and axillary clearance
(25 trials of Mast+AC  RT) on local recurrence and on breast cancer mortality
1428 women with node-negative disease
Effect of radiotherapy after mastectomy and axillary clearance
(25 trials of Mast+AC  RT) on local recurrence and on breast cancer mortality
8505 women with node-positive disease
Effect of radiotherapy on breast cancer mortality and on all-cause mortality
after mastectomy with axillary clearance (Mast+ACRT)
8505 women with node-positive disease
Radiotherapy after mastectomy with axillary clearance (Mast+ACRT) in all women
(9933 women, 86% with node-positive disease)
Radiotherapy after mastectomy with axillary clearance
(Mast+ACRT) in women with node-negative disease
(1428 women)
Radiotherapy after mastectomy with axillary clearance
(Mast+ACRT) in all women with node-positive disease
(8505 women, many with the actual number of involved nodes unknown)
Radiotherapy after mastectomy with axillary clearance
(Mast+ACRT) in women with 1-3 involved lymph nodes (pN1-3)
(1890 women)
Radiotherapy after mastectomy with axillary clearance (Mast+ACRT)
in women with 4 or more involved lymph nodes (pN4+)
(1868 women)