How Should We Manage Breast Cancer in the Breast, or Buddy, Can You Paradigm? (1995)

It is easy to define the goals of the best locoregional therapyfor women with invasive or noninvasive breast cancer. Thesegoals are quite obviously the best survival, the least disfigure-ment, and the least likelihood of significant systemic toxicity.What is not so easy to define are the optimal ways of achievingany one of these three goals without compromising any of theothers. The good news is that, within the past decade, a varietyof paradigm-shifting clinical trials have been completed thatprovide a significantly higher degree of confidence in the ef-ficacy of some of the choices that we offer our patients. In part,this improved situation is based on an awareness that theachievement of each of these three goals is more independentthan was previously thought. Unfortunately, not everyone ac-cepts this as proven, given the fact that most invasive breastcancers in the United States are still managed by mastectomy.Nearly a century ago, the Halstedian view of breast cancer(and, in fact, most malignancies) held that their growth was ex-pansile and that dissemination occurred through locally acces-sible lymphatic channels. A direct corollary of this belief wasthat a large enough extirpative circle drawn around the tumorwould totally remove it and the patient. This biologicalconcept, combined with a far more advanced presentation ofmost breast cancers common years ago, achieved local controlat the expense of very substantial disfigurement. Equally un-deniably, many women treated in this way, albeit a minority inaggregate, survived for decades to die of other unrelated causes.The development by Fisher et al. (/) of the notion that thepredominant lethality of breast cancer was due to systemichematogenous spread, which had generally occurred prior tolocal therapy, gave rise to the idea that local management mightnot have a very significant impact on survival. A series of ran-domized trials involving even less surgical treatment of thebreast, with or without additional radiation therapy, have tendedto support this notion; virtually all trials showed no decrementin survival associated with surgery that was limited first to thebreast alone and later to the tumor and immediately surroundingtissue (I-6). What is also clear is that the removal of increasing-ly less breast tissue and the omission of radiation therapy alllead to increasing rates of local treatment failure within thebreast. For example, in the National Surgical Adjuvant Breastand Bowel Project (NSABP) B-06 protocol (/), patients whoreceived radiation therapy following lumpectomy had more thana threefold reduction in breast recurrences. Similarly, the MilanCancer Institute trial (7), which compared quadrantectomy withtumorectomy, showed that the more extensive local surgeryresulted in more than a threefold reduction in breast recurrencesat the expense of greater disfigurement. On the basis of theseand other studies, it is obvious that both increasing the extent oflocal breast surgery and adding adjuvant radiation therapy to thebreast can more effectively cure breast cancer. Clearly, cureof breast cancer does not guarantee avoidance of systemicmetastases and eventual death from breast cancer. On the otherhand, it is certain that adequate local treatment of some breastcancers does result in the of patients who would otherwiseeventually become incurable if left untreated. These argumentsare well summarized in the current American Society of ClinicalOncology Kamofsky Memorial Lecture delivered by Hellman(8). Among many data that could be cited, the unequivocal im-provement in survival produced by screening mammography es-tablishes the fact that some breast cancers behave as localizeddiseases and if left alone long enough (the unscreened popula-tion) will have systemic recurrences (9).The most important question, however, is whether or not anysubset of patients in whom viable invasive or noninvasive breastcancer cells are retained in the breast following incomplete localtherapy develop disseminated disease as a result of the failure toremove them. This issue is probably the single, most importantscientific argument given for mastectomy following a diagnosisof noninvasive duct cell carcinoma of the breast. The articlefrom the Milan Cancer Institute, appearing in this issue of theJournal (10), attempts to address this question. More than 2000women sequentially treated with quadrantectomy and radiationtherapy were assessed for either local or distant treatmentfailure; the prognostic variables predicting either and time totreatment failure were presented. These authors, as well asothers (11-15), noted that some prognostic variables, such as ageunder 40 years and local lymphatic permeation, predicted forboth local treatment failure and distant disease. Other variables,