Breast Conservation: an option for more breast cancer patients

Breast Conservation: an option for more breast cancer patients

22 Oct 2015

Although large tumor size has been regarded as a relative contraindication for breast conservation therapy (BCT), that need not always be the case, researchers reported.

A retrospective study of almost 6,000 Medicare patients found that, in women with tumors measuring >5 cm, BCT provided overall survival and disease-specific survival equivalent to mastectomy and similar to that of patients with smaller primary tumors, according to Richard J. Bleicher, MD, of Fox Chase Cancer Center in Philadelphia, and colleagues.

Breast conservation therapy VS mastectomy

In the study, Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked cases were used to identify patients’ ages 66 years and older undergoing breast conservation for invasive, non-inflammatory, non-metastatic breast cancer.

The results showed that of 5,685 patients with tumors measuring >5 cm who underwent breast surgery, 15.6% receiving BCT. Mean ages of the patients and tumor sizes were similar.

Predictors of BCT included:

• Neoadjuvant chemotherapy and postoperative radiotherapy use
• Higher income
• Breast cancer as a first malignancy
• Higher Charlson Comorbidity Index

Predictors of mastectomy included:

• Younger age
• Non ductal histology
• Higher grade
• Numbers of lymph nodes examined and found to be positive
• American Joint Committee on Cancer stage III disease
• Postoperative chemotherapy use
• Residential region of the country

Equivalent results between the two treatment methods

While the overall survival and disease-specific survival improved over time for both BCT and mastectomy among women with tumors measuring >5 cm, the overall survival and disease-specific survival equivalence between the two treatments remained the same throughout the period of study (1992-2009). Median follow-up was 7 years.

The incidence of multifocality and multicentricity (MF/MC) remains "an issue of pertinence for local resection," noted the investigators. Data do not demonstrate an increase in disease recurrence among patients with tumors exhibiting MF/MC versus unifocality, and when adjusting for other prognostic factors, MF/MC does not appear to correlate with survival, they said.

Larger tumors, if they can be resected totally and breast cosmetics conserved, can be treated with breast preservation, added David R. McCready, MD, Gattuso Chair in Breast Surgical Oncology at the Princess Margaret Cancer Centre and University of Toronto, who was not involved in the study.

However, survival following treatment for breast cancer is more dependent on the biology and behavior of the tumor and its response to systemic therapy than the extent of surgery, said McCready.

“BCT may remain an option for patients with larger tumors”

Data from the current study reinforce the belief that the option should be provided to all patients who are clinically amenable to local surgical resection, said the investigators. "We recommend that tumor size no longer be considered a relative contraindication in this subgroup of patients when breast size can accommodate such a resection," they said.

"Despite exclusion from randomized trials, BCT may remain an option for patients with larger tumors when deemed clinically and cosmetically amenable to surgical resection," wrote the authors. "The current study is consistent with the few smaller retrospective series that have suggested that a tumor size >5 cm should not remain a relative contraindication to BCT," they said.

 Important psychological benefits to providing BCT

Adjusted overall and breast cancer-specific survival were not different between patients treated with BCT and mastectomy, with each improving over time. The study showed that although the use of BCT in women with T3 tumors in the Medicare population has been steadily increasing since 1992, only one in five patients with T3 tumors >5 cm were being offered BCT as late as 2009. Two possible explanations include lack of data demonstrating its safety and current guidelines indicating that tumor size >5 cm is a relative contraindication to BCT.

Still, the increasing trend in the use of BCT is encouraging, because it suggests that more women are being given more surgical options, said the investigators.

There are important psychological benefits to providing BCT as an option for patients, they noted. Prior prospective data from the European Organization for Research and Treatment of Cancer have demonstrated a correlation between BCT and improved quality of life signified by improved body image, treatment satisfaction, and no increase in fear of disease recurrence.

 

Source: MedPage Today