Is chemotherapy effective in reducing the local failure rate in patients with operable breast cancer?

Abstract

To evaluate the role of chemotherapy in local control of primary breast cancer, the incidence of local failure was evaluated in 768 patients treated with surgery and adjuvant, combination chemotherapy that contained fluorouracil, doxorubicin, and cyclophosphamide (FAC) at our institute between 1974 and 1982. Of these patients, 429 received postoperative irradiation (XRT) before adjuvant therapy. A group of 178 historical control patients had mastectomies and received irradiation after surgery without chemotherapy. The rates of locoregional recurrence alone in the three groups were as follows: FAC, 12%; FAC plus XRT, 5%; and XRT, 10%. The difference in recurrence rates between the FAC group and the FAC plus XRT subgroup was significant (P less than 0.01). Local failure rates were evaluated by stage and nodal status; patients with Stage III disease and those with four or more disease-positive nodes had a higher incidence of local failure than did patients with Stage II disease or those who had one to three positive nodes. Systemic chemotherapy and local therapies resulted in 50% local control at the time of locoregional recurrence in patients treated with FAC, whereas local control was achieved in 18% of patients with local recurrence in the XRT subgroups. Overall life-time local control of disease was similar whether irradiation was administered initially (in the period after operation) or at the time of local recurrence. Irradiation after mastectomy remains an integral part of a combined modality approach in selected groups of patients.

Radiation therapy for operable breast cancer

“…Other indications for radiation then were patients with locally advanced or inflammatory breast cancer, positive margins, dermal lymphatic invasion, or extranodal lymph node extension. 48 However, the long-term effects of postmastectomy radiation continued to be a concern limiting utilization of radiation. Radiation to the chest wall and regional lymph nodes was associated with arm edema, decreased range of motion of the shoulder, chronic skin ulceration, respiratory insufficiency, rib or shoulder fractures, and fear of second malignancies.…”

“…In many studies, this risk was >20% in subgroups of lymph-node-positive patients and increased with increasing numbers of lymph nodes and greater tumor size. [46][47][48] Tumor size >5 cm and 4 positive lymph nodes have become the clearest indications for postmastectomy radiation to the present day. Other indications for radiation then were patients with locally advanced or inflammatory breast cancer, positive margins, dermal lymphatic invasion, or extranodal lymph node extension.…”

“…47,54 Buzdar et al reported that radiation for stage II and III operable breast cancer, even with doxorubicin (Adriamycin)-based chemotherapy, could reduce local failure significantly better than either modality alone. 48 However, in the same study, radiation at the time of recurrence was seen as effective enough to question the routine role of elective adjuvant radiation versus delayed radiation for salvage. Routine postmastectomy radiation was recommended for high-risk patients including those with locally advanced or inflammatory disease, positive surgical margins, extensive dermal lymphatic invasion, or extensive extranodal axillary disease.…”

Locoregional Failure 15 Years after Mastectomy in Women with One to Three Positive Axillary Nodes with or without Irradiation

“…The extent of radiation field to be used for PMRT is also being debated [23,26,28,29]. In agreement with the findings of other reports [1,5,8,17,27], the results of the current investigation demonstrate that the chest wall is the site at greatest risk of recurrence in patients undergoing mastectomy. Therefore, when PMRT is given, treatment of the chest wall is mandatory.…”

“…There is consensus on the routine use of PMRT in patients with T1/2 tumors and four or more positive axillary lymph nodes, but whether or not to use it in patients with one to three involved nodes is still being debated [7,11,12,23,26,28], as well as investigated in clinical trials [11,23]. The LRR rates in patients with one to three involved nodes in the Danish [21,22] and British Columbia [25] trials were much higher than in other series [1,8,10,18,27,30]. The importance of primary tumor size was not a central issue in the above trials [21,22,25].…”