Breast conserving therapy and mastectomy revisited: Breast cancer‐specific survival and the influence of prognostic factors in 129,692 patients

Abstract

This large population-based study compared breast-conserving surgery with radiation therapy (BCT) with mastectomy on (long-term) breast cancer-specific (BCSS) and overall survival (OS), and investigated the influence of several prognostic factors. Patients with primary T1-2N0-2M0 breast cancer, diagnosed between 1999 and 2012, were selected from the Netherlands Cancer Registry. We investigated the 1999-2005 (long-term outcome) and the 2006-2012 cohort (contemporary adjuvant systemic therapy). Cause of death was derived from the Statistics Netherlands (CBS). Multivariable analyses, per time cohort, were performed in T1-2N0-2, and separately in T1-2N0-1 and T1-2N2 stages. The T1-2N0-1 stages were further stratified for age, hormonal receptor and HER2 status, adjuvant systemic therapy and comorbidity. In total, 129,692 patients were included. In the 1999-2005 cohort, better BCSS and OS for BCT than mastectomy was seen in all subgroups, except in patients < 40 years with T1-2N0-1 stage. In the 2006-2012 cohort, superior BCSS and OS were found for T1-2N0-1, but not for T1-2N2. Subgroup analyses for T1-2N0-1 showed superior BCSS and OS for BCT in patients >50 years, not treated with chemotherapy and with comorbidity. Both treatments led to similar BCSS in patients <50 years, without comorbidity and those treated with chemotherapy. Although confounding by severity and residual confounding cannot be excluded, this study showed better long-term BCSS for BCT than mastectomy. Even with more contemporary diagnostics and therapies we identified several subgroups that may benefit from BCT. Our results support the hypothesis that BCT might be preferred in most breast cancer patients when both treatments are suitable.Large randomized controlled trials (RCTs) in the 1980s have shown equal survival for breast-conserving therapy (breastconserving surgery plus radiation therapy, BCT) and mastectomy in early stage breast cancer.

Current practice and short-term outcomes of therapeutic mammaplasty in the international TeaM multicentre prospective cohort study

“…TM may provide women with a safe alternative to mastectomy or offer improved cosmetic and quality‐of‐life outcomes compared with standard BCS, but high‐quality evidence to support the safety and effectiveness of the technique is lacking. RCTs comparing TM with other techniques are largely inappropriate due to patient and surgeon preference, as well as mounting evidence suggesting long‐term survival benefits for patients undergoing BCS and radiotherapy compared with mastectomy. This large prospective multicentre cohort study assessed current practice and short‐term outcomes of the technique and provided ‘real world’ data from 50 centres regarding complications, rates and management of incomplete excision, and impact of TM procedures on the delivery of adjuvant therapy.…”

Mastectomy May Be an Inferior Oncologic Approach Compared to Breast Preservation

“…Multiple randomized studies have demonstrated that breastconserving therapy (partial mastectomy plus whole breast radiation) can yield survival outcomes equivalent to those of mastectomy (1). However, newer population-based data suggest that breast cancerespecific survival and overall survival with breast-conserving therapy may actually be better than those with mastectomy (2)(3)(4)(5)(6)(7)(8). How is this possible?…”

“…We suggest that adjuvant RT may have a more important role when surgical practice evolves to reduce the volume of tissue resected during breast and axillary surgery. The integral role of adjuvant RT in breast-conserving therapy may explain why it is associated with better breast cancerespecific survival and overall survival relative to mastectomy in several recent population-based studies (2)(3)(4)(5)(6)(7)(8). This improvement in survival is strongest in earlystage subgroups (in which postmastectomy RT is seldom used) and in those with comorbiditiesdfor whom systemic chemotherapy is less often applied (2, 4, 8)dsuggesting possible multimodality interactions.…”

Patient-Reported Outcome Measures May Add Value in Breast Cancer Surgery

“…In early-stage breast cancer, high survival rates are achieved irrespective of type of surgery, whether breast-conserving therapy (BCT; breastconserving surgery with breast radiation therapy) or mastectomy (with or without reconstruction). [4][5][6] Consequently, anticipation of outcomes reflecting physical, sexual, and psychosocial functioning is very important in treatment decision-making in these patients.…”