Additional Treatment Must Accompany Lumpectomy
An alarming new study published in the September 30th issue of the British medical journal The Lancet has determined that thousands of American women who have undergone breast-conserving surgery (lumpectomies) for early-stage breast cancer are not receiving appropriate follow-up care.
A 1990 consensus panel of the National Institutes of Health (NIH) recommended that all women undergoing a lumpectomy also have axillary node dissection (removal of one or more nearby lymph nodes to check for cancer spread) and postoperative radiation therapy.
However, according to research by Dr. Ann Butler Nattinger of the Medical College of Wisconsin and colleagues, fewer women with early-stage breast cancer are now receiving these additional procedures than a decade ago. They based their conclusion on an analysis of 144,759 records from the Surveillance, Epidemiology, and End Results (SEER) database of the National Cancer Institute.
In a lumpectomy, only the tumor and an extra margin of surrounding tissue are removed, leaving the breast essentially intact. A mastectomy involves the removal of the entire breast and, sometimes, additional tissue. In an axillary node dissection, a separate incision is made in the underarm area to remove underarm lymph nodes to check for cancer spread.
According to the findings of Nattinger's team, the proportion of women who received these additional recommended procedures-axillary node dissection and radiation therapy-dropped from an average of 88 percent during the period 1983-1989 down to 78 percent by the end of 1995.
Thus, while more women were having lumpectomies, a declining percentage of them were having the "total package" of recommended procedures as specified in the NIH guidelines. (It should be noted that omitting radiation therapy in carefully designed clinical trials is an appropriate option.)
The authors suggested that this decline in appropriate adjuvant care might be resulting because breast-conserving surgery is more complex than total mastectomy. It "requires a separate incision for axillary lymph node dissection, postoperative radiotherapy, attention to the tumor margins, and attention to the cosmetic result," they wrote. Yet, this is no excuse for not providing "appropriate care," they argued. Women treated with breast-conserving surgery who don't get radiotherapy have a 35 percent rate of local recurrence, and "the use of this approach without radiotherapy has been associated with higher mortality in two population-based observational studies," they noted.
In an accompanying editorial in the same issue, Dr. Richard Sainsbury of the Huddersfield Royal Infirmary, UK, added: "The dangers of skipping axillary dissection are under-treatment and under-staging. ... Omitting radiotherapy after breast conservation increases the risk of local recurrence by at least two-fold."
According to a report published in the American Journal of Public Health, the percentage of patients with early-stage breast cancer who opt for breast-conserving surgery (vs. mastectomy) increased from 27.9 percent in 1988 to 54.1 percent in 1995. Dr. Cyllene Morris of the California Cancer Registry and associates based their figures on a study of more than 100,000 California women.
They found that women of all racial and ethnic groups were increasingly turning to breast-conserving surgery (lumpectomy) as a treatment for their breast cancer. However, less-educated women and those of Asian or Hispanic descent were less likely than other women to choose this procedure.
African-American breast cancer patients were the most likely to undergo a lumpectomy, they noted, followed by Caucasian women. Those who lived in undereducated areas were 25 percent less likely to undergo the procedure than women who lived in more educated neighborhoods. Also, older women were less likely than younger women to have a lumpectomy, the researchers wrote.
A disturbing report in the Journal of Clinical Oncology noted that younger women who underwent lumpectomy to remove non-invasive breast cancer were more likely to experience a recurrence than older women.
Dr. Frank Vicini and colleagues from William Beaumont Hospital in Royal Oak, Michigan reviewed the long-term results of breast-conserving therapy for 146 women with ductal carcinoma in situ (DCIS). After a median follow-up period of 7.2 years, they found that women with DCIS who were younger than 45 and underwent lumpectomy faced dramatically higher rates of recurrence than older women. However, the factor most associated with the need for a second surgery was not age, but rather the extent of the original surgery.
Vicini suggested that younger women were more likely to have smaller excisions-less surrounding tissue was removed-than older women, partly for cosmetic reasons. Unfortunately, he noted, "in younger women, cancer can be spread over a slightly larger area in the breast because the tissue is more dense and has more ducts." Therefore, he wrote, "the extent of excision may be related to the less optimal results that have been observed in these [younger] patients."
In another study, The European Organization for Research and Treatment of Cancer recently reported that breast cancer patients with tumors up to 5 centimeters (cm) in diameter can be treated almost as successfully with lumpectomy as with modified radical mastectomy. Lumpectomy had originally been recommended for tumors that are 4 cm or smaller.
Writing in the Journal of the National Cancer Institute, a team of researchers from England, the Netherlands, Belgium and South Africa evaluated the cases of 868 breast cancer patients to see if women treated using lumpectomy for tumors up to 5 cm had a different overall survival rate than those treated with mastectomy for these larger tumors.
They found that after 10 years the survival statistics for the two groups of women were almost the same. Sixty-six percent of the mastectomy patients survived to 10 years and 65 percent of the lumpectomy patients survived to 10 years. The findings were expected to fuel the growing demand for lumpectomy as an alternative to mastectomy for many more breast cancer patients.
Lumpectomy is becoming a favorable surgical option for a rapidly growing number of breast cancer patients. However, while the number of these breast-conserving surgeries is on the rise, the use of crucial adjuvant treatments such as lymph node detection and radiation therapy is not keeping pace. Hopefully the Lancet article will serve as a wake-up call to both physicians and their patients to reverse this dangerous trend.
SOURCES:
The Lancet, September 30, 2000; 1124-1125, 1148-1153
American Journal of Public Health, February 2000; 90:281-284
Journal of Clinical Oncology, January 2000; 18:296-306
Journal of the National Cancer Institute, July 19, 2000; 92:1143-1150
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