Comparing Radical Mastectomy with Quadrantectomy, Axillary Dissection, and Radiotherapy in Patients with Small Cancers of the Breast

Veronesi, Umberto; Saccozzi, R; M, Del Vecchio; Banfi, Alberto; Clemente, Claudio; M, De Lena; Gallus, Giuseppe; Greco, Marco; Luini, Alberto; Marubini, Ettore; Muscolino, G.; Rilke, F; Salvadori, B; Zecchini, A M; Zucali, R

doi:10.1056/nejm198107023050102

Cited by 1,451 publications

(473 citation statements)

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“…21 In fact, there were considerable differences between the Italian registry areas in the use of breast-conserving surgery. Proportionally more women underwent such surgery in Florence, because of limited stage and perhaps also because of modern treatment protocols had been adopted in relation to the imminent adoption of screening.…”

Section: Discussionmentioning

confidence: 99%

Differences in stage and therapy for breast cancer across Europe

Sant

2001

Int. J. Cancer

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We examined variations in stage, diagnostic workup and therapy for breast cancer across Europe. Seventeen cancer registries in six European countries contributed 4,480 cases diagnosed in 1990 -91. The clinical records of these cases were examined, and the distribution of stage, diagnostic examinations and therapy were analyzed. Stage was earliest in the French registries, followed by those of Italy and Eindhoven (Netherlands). The proportion of stage I cancers was highest in the French areas with screening in place. Estonia, the English registries and Granada (Spain) had the most advanced stage at diagnosis. Use of liver ultrasonography varied from 84% (Italian registries) to 18% (Granada). Bone scan use varied from 81% (Italian registries) to 15% (Mersey, UK). The highest proportions treated by breast-conserving surgery were in the French (57%) and English registries (63%); the lowest were in Estonia (6%) and Granada (11%). The highest proportions of Halsted mastectomies were in Italy (19%) and Granada (8%). In all countries except England, 90% of operations included axillary lymphadenectomy. Medical treatment only was given to 8% of (mostly advanced) cases overall. Estonia (21%) and the English registries (14%) had the highest proportions of patients given medication only. Chemotherapy was given to low proportions of nodepositive cases in the Italian (76%) and English (74%) areas; breast-conserving surgery for stage I tumors varied from 24% in Granada to 84% in England. These wide differences in breast cancer care across Europe in the early 1990s indicate a need for continual monitoring of past treatments to help ensure application of the most effective protocols. © 2001 Wiley-Liss, Inc. Key words: breast cancer; population registries; care; survival; EuropeThe Eurocare project, which involved 45 population-based cancer registries in 17 European countries, revealed large variations in survival for breast cancer across Europe. These variations were attributed mainly to differences in stage at diagnosis, but the data also suggested that differences in the quality of care played a role. 1,2 Studies of patterns of cancer care are usually carried out on hospital series of patients selected with respect to the general population of cancer sufferers. These studies almost always originate from specialist oncological centers and usually exclude patients treated in non-specialist structures (general hospitals) and those not treated in hospital. [3][4][5][6] To provide a reliable picture of how cancer patients are cared for in current medical practice, it is necessary to study all the cases occurring in the population, or representative samples thereof. Only population-based cancer registries collect data on all cancer cases, and analyses deriving from them can provide indications as to the overall effectiveness of health care. However, the information on disease stage at diagnosis and on treatment collected routinely by most cancer registries is limited and insufficient to illuminate in detail the reasons for difference...

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Section: Discussionmentioning

confidence: 99%

Differences in stage and therapy for breast cancer across Europe

Sant

2001

Int. J. Cancer

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“…Post-operative adjuvant radiotherapy, delivered to patients with localized node-negative breast carcinoma (NNBC), has the aim to eradicate any micrometastases that may still be present in the breast after surgery (Veronesi et al, 1981;Fisher et al, 1989;Liljegren et al, 1994). However, there is a significant number of patients (25-30%) with only locally treated NNBC in which the tumour relapsed (McGuire, 1988).…”

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Does vascular endothelial growth factor (VEGF) predict local relapse and survival in radiotherapy-treated node-negative breast cancer?

et al. 1999

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SummaryThe aim of this study was to determine the association of vascular endothelial growth factor (VEGF) content in 302 consecutive nodenegative breast cancer (NNBC) patients treated with only locoregional radiotherapy to relapse free-(RFS) and overall survival (OS). VEGF content in tumour cytosols was measured by an enzymatic immunoassay for the major isoform VEGF 165 . The median age was 56 years, the median follow-up time 56 months. A wide range (0.01-144.79 pg µg -1 DNA) of VEGF content was found (median 1.92). Significant associations were found between VEGF and oestrogen receptor (ER) content, progesterone receptor (PR) and tumour size (P = 0.005). Univariate analysis displayed significant reduced RFS and OS for patients with higher VEGF content (P = 0.0113 and P = 0.0075 respectively). A total of 43 recurrences have been found (ten local relapses within the breast, five in the axillary or supraclavicular lymph nodes and 28 distant metastasis). There was no significant correlation between the localization of the relapse and the VEGF content. Multivariate analysis suggested VEGF as the only predictor of OS (relative risk (RR) = 3.6, 95% confidence interval (CI) = 0.97-13.37), and in patients with T1 tumours (n = 236) the multivariate analysis clearly displayed VEGF as the only independent predictor of both RFS and OS (RR = 5.1, CI = 1.07-24.59). In the subgroup with ER-positive tumours (n = 229), multivariate analysis showed VEGF as the only significant predictor of RFS and OS (RR = 10.44, CI = 1.26-86.38). The results suggest VEGF 165 as a predictor of RFS and OS in NNBC patients treated with locoregional radiotherapy, comprising especially patients with favourable prognosis of T1 tumours, or ER-positive tumours. The high VEGF expression might define a radioresistant phenotype, or indicate an early distant spread which might require adjuvant systemic treatment.

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“…Several trials have led to a better understanding of the possible results of different types of primary treatment. Breast-conserving therapy, limited surgery followed by high-dose radiation, has been shown to be as effective as modified radical mastectomy for most operable patients (Veronesi et al, 1981). For mastectomy patients, routine post-operative radiotherapy is now usually considered unnecessary (Edland, 1988;Harris & Hellman, 1988).…”

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Changes in use of breast-conserving therapy in years 1978-2000

Koning

Dongen²,

Maas³

1994

Br J Cancer

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Summary The treatment of breast cancer patients has changed rapidly in the past decade, but empirical data at local and national level are scarce. Predicting the consequences of screening for primary treatment is consequently difficult. The aim of this analysis of records on admissions to hospital of women with breast cancer and/or for breast surgery together with a survey of all Dutch radiotherapy departments is to show the change in breast-conserving therapy and other primary treatment before the start of breast cancer screening in The Netherlands. There was a modest increase in breast-conserving therapy after 1981, coinciding with the first publication on its trial, followed by a sharp increase between 1985 and 1990, after the second publication. At the end of that 5 year period, 36% of all women with newly diagnosed invasive breast cancer underwent this type of surgery. Breast-conserving surgery is always followed by radiotherapy, but there has been a clear reduction in post-operative radiation after mastectomy. The percentage of breast-conserving therapy is at present higher in The Netherlands than in the USA. Implementing the Dutch screening programme will result in a maximum increase in breast-conserving therapy at national level of 34%, which stabilises at + 21%, or a 50% maximum increase at local level. The number of women treated by mastectomy will ultimately decrease by 9%. Given the rapidity of change towards the use of breast-conserving surgery, which is enhanced by screening, recent information will be needed in predicting capacity and assessing whether screen-detected women are treated adequately.The treatment of breast cancer patients has changed rapidly in the past decade. Several trials have led to a better understanding of the possible results of different types of primary treatment. Breast-conserving therapy, limited surgery followed by high-dose radiation, has been shown to be as effective as modified radical mastectomy for most operable patients (Veronesi et al., 1981). For mastectomy patients, routine post-operative radiotherapy is now usually considered unnecessary (Edland, 1988;Harris & Hellman, 1988). It could be assumed that treatment practice would be influenced by the information from these trials, but empirical data at national and local level are scarce in most countries (Farrow et al., 1992;Chouillet et al., 1994).At the same time, countries have started to implement breast cancer screening, as trials have shown that a reduction in mortality from breast cancer can be expected for screened women aged 50-69. The impact on the number and type of surgical procedures and radiotherapy will be great as a result of both the temporary increase in the number of women detected with breast cancer and the increase in early cancers (de Koning et al., 1990). Bottlenecks in capacity are expected, but there is a lack of empirical data to support this hypothesis.As we were especially uncertain about the development of breast-conserving therapy (outside a screening programme), we have analysed dat...

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Comparing Radical Mastectomy with Quadrantectomy, Axillary Dissection, and Radiotherapy in Patients with Small Cancers of the Breast

Cited by 1,451 publications

References 15 publications

Differences in stage and therapy for breast cancer across Europe

Differences in stage and therapy for breast cancer across Europe

Does vascular endothelial growth factor (VEGF) predict local relapse and survival in radiotherapy-treated node-negative breast cancer?

Changes in use of breast-conserving therapy in years 1978-2000

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