The Actual Extent of Mastectomy: A Key to Survival

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PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 30 ¦ Number 3 ¦ Spring 1987 THE ACTUAL EXTENT OF MASTECTOMY: A KEY TO SURVIVAL DONALDJ. FERGUSON* During the past 3 decades, surgery for breast cancer has been gradually attenuated by a turn of thought that began in the United Kingdom and has spread worldwide, holding that efforts to excise all the local and regional disease do not improve results. It is now widely taught that "dissemination rates are unaffected by the type of primary treatment" [1], "operable breast cancer is a systemic disease" [2], and "local treatment does not influence survival" [3]. One basis for these beliefs is the appearance of disseminated cancer many years after treatment that is locally effective. Another reason is the similarity in rates of survival after nominally different types of mastectomy. If, on the other hand, it may be observed by a more careful scrutiny of the evidence that the actual extent of mastectomy can affect survival and that a significant proportion of mastectomy patients are cured—in the sense that they live a normal life span without recurrent cancer—the quoted generalizations are seen to apply only to a certain fraction of operable patients. Members of this doomed subgroup cannot be individually recognized at the time of mastectomy and therefore cannot safely be treated differently from the others. It may, of course, be postulated that all cancer patients, or all human beings for that matter, have dormant cancer cells that never proliferate, but this theory has no apparent usefulness. The purpose of this essay is to review the evidence for and against mastectomy, by showing that the present, generally disparaging opinion *Department of Surgery, University of Chicago, 5841 Maryland Avenue, Chicago, Illinois 60637.© 1987 by The University of Chicago. All rights reserved. 003 1-5982/87/3003-054 1$01 .00 Perspectives in Biology and Medicine, 30,3 ¦ Spring 1987 | 311 TABLE 1 Ten-year Survival in Randomized Comparisons of the Extent of Mastectomy Project Types of Mastectomy Survival Local Recurrence P (%) Cases (N) 1st series 2d series Total vs. I—III extendedI— III TotalII vs. radicalII—III Total vs. radical Partial vs. radical Partial vs. radical Partial vs. radical Radical vs. extended Total vs. radical Total vs. radical Total vs. radical Quadrant vs. radical I—III I—III I I II II I—III I—III I I II II II II I (<2 cm) I (<2 cm) 44 48 46 49 52 61 57 52 59 68 35 49 53 56 54 58 39 38 31 35 79 78 NS <.05 NS <.002 <.05 .40 .50 NS 21 24 Not NSgiven 23 15 34 16 33 8 63 26 24 14 10 8 16 Not .90given NS Not given <.003 <.001 <.001 <.05 NS NS NS NS 199 183 113 91 242 256 112 108 122 130 70 80 746 697 365 362 294 292 159 148 352 349 312 Nodes Found (N) Adjuvants Internal Axillary Mammary Randomization X-ray Rads EndoDrugcrineMethodExclusions (9i ) Not described Not described Not described Not described 12 15 15 15 15 15 2-4 Not described Not described 4300 0 3300 3300 4500 0 3800 3000 3800 3000 3800 3000 Yes Yes Yes Yes 6000 0 4000 0 6000 0 Yes Yes Yes Yes Case40 no. 45 OK3 deaths OK OK OK OK Not given Not given 15 0.3 2 5.7 11 Kaae [9, 10] Brinkley[ll, 12] Bruce [5, 13] Atkins [6, 7] Lacour [14, 15] Fisher [16, 17] Lythgoe [3, 18] Veronesi [19, 20] 313 is not well founded and by demonstrating that not only the extent but the detailed care applied to the resection determines survival. To relate extent to survival, we need a randomized comparison of defined variations in resection with adequate follow-up. Results up to 5 years have been shown to mislead in part because of the often slow progression of breast cancer (4 vs. 5, 6, 6 vs. 7). Patients who remain well for 15—20 years after radical mastectomy have little further risk of recurrence , and their average life expectancy is then the same as that of a matched control population [8]. There is only one randomized study carried to 20 years [7]. If we compromise by accepting 10 years, only seven other projects meet these minimum requirements. We can briefly examine all of this evidence; the studies and their references are listed in table 1. Descriptions of the Surgery Names of the various types of mastectomy are listed in table 1 . The actual resections performed are found to vary within study groups as well as between studies that are nominally of the same procedure. Insofar as such variations may affect survival, they obviously impair the validity of any conclusions that are drawn, and they are therefore described here in more detail. The smallest operation was partial mastectomy. In project 4, it was called "extended tylectomy" and defined as "wide excision of the lump together with the surrounding breast tissue within 3 cm of palpable or visible growth" [6]. Deep and peripheral tumors obviously could not have such a margin. Patients with medial tumors were excluded from the study, perhaps for this reason. Another variation of partial mastectomy called "quadrantectomy" was studied in project 8, in which only patients with no palpable nodes and cancers less than 2 cm in diameter, as measured by the pathologist after excision, were included; 45 percent of the tumors were less than 1 cm in diameter [19]. The involved segment of the breast was removed, including skin and fascia, with at least 2 cm of tissue surrounding the cancer. Through the same or a separate incision, the axillary nodes (numbers not given) were dissected out, with removal of part of the minor pectoral muscle. Cosmetic results were thought to be good in "more than 70 percent of the cases." Total (simple) mastectomy was evaluated in projects 1, 2, 3, 6, and 7. In project 2, 79 percent of total mastectomies included axillary lymph nodes, and, in 42 percent of these patients, there were nodal metastases. Probably the most prominent nodes were removed, and this may have altered survival [21]. In project 6, total mastectomy...

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