Breast Conservation Linked to Higher Long-term Risk of Local Breast Cancer Recurrence Than Mastectomy

Laurie Barclay, MD

November 03, 2003

Nov. 3, 2003 — Women younger than 40 years who opt for breast conservation surgery have a higher long-term risk of local recurrence of breast cancer than those undergoing mastectomy, according to the results of a 22-year follow-up of a randomized trial published in the Nov. 3 issue of the Annals of Oncology. The investigators urge aggressive follow-up but acknowledge that these findings need corroboration.

"Our results confirm that a young age at diagnosis is a strong prognostic factor for local recurrence in breast conservation patients and not in patients treated by mastectomy," lead author Rodrigo Arriagada, from the Instituto de Radiomedicina in Santiago, Chile, says in a news release.

"If these results are corroborated, younger patients should be informed of the higher risk of local recurrence and the need for indefinite follow-up if they choose conservation treatment," Arriagada says. "However, this higher risk does not decrease the probabilities of long-term cure, as overall survival is the same, independently of the initial surgery performed. Indeed, local recurrence after breast-conserving surgery may be successfully treated if there is early diagnosis."

This study, from the Institut Gustave-Roussy and INSERM in Villejuif, France, followed 179 patients with breast cancer enrolled in the 1970s in a trial evaluating the effects of lumpectomy combined with breast irradiation (88 patients) vs. mastectomy (91 patients). At enrollment, age, tumor size (under 20 mm) and grade, and lymph node status were similar in both groups.

Over time, both groups had similar rates of survival and metastasis. Although risk of local recurrence was five-fold less in the conservative surgery group during the first five years than it was in the mastectomy group, it was 12-fold greater after five years. During the first five years, the mean age of the patients who developed local recurrence was 57 years in the conservative surgery group and 53 years in the mastectomy group. The mean age of patients in the conservative surgery group who had local recurrence after 5 to 10 years was 46 years, and after 10 years it was 44 years. The only patient in the mastectomy group who had a local recurrence after five years was aged 59 years.

An accompanying analysis of 1,847 similar patients from the Institut Gustave-Roussy's database included 632 women who had conservative surgery and 1,215 who had mastectomy. Late recurrence of breast cancer was more frequent in the conservative surgery group, especially among women younger than 40 years at diagnosis.

Fifteen years after diagnosis, the incidence of local recurrence and contralateral breast cancer was 12% in both conservative surgery and mastectomy groups for those older than 61 years; 12% in the conservative surgery group and 5% in the mastectomy group for women aged 51 to 60 years; 13% in the conservative surgery group and 7% in the mastectomy group for women aged 41 to 50 years; and 36% in the conservative surgery group and 12% in the mastectomy group for women up to 40 years of age.

In both analyses, women had not received adjuvant treatment with tamoxifen. Dr. Arrigada does not advocate mastectomy for all women younger than 40 years, but he recommends that younger women opting for breast conservation have wider lumpectomy margins, surgical clips placed in the tumor bed to improve the accuracy of radiotherapy, a good radiotherapy boost technique, and adjuvant tamoxifen therapy in patients with hormone-responsive tumors. The European Organisation for Research and Treatment of Cancer (EORTC) is currently planning a new trial to evaluate the role of higher boost doses in younger women.

"We should not forget that the increased risk after 15 years is limited — 20% to 25%," Dr. Arrigada says. "If a young patient of 35 is able to conserve an aesthetic breast for this time, maybe the impact on her quality of life will be a little bit less at 55 years, and in any case three women out of four will be free of local recurrence. This information should be given to patients to enable them to choose between breast conserving surgery and mastectomy with breast reconstruction. We should also be aware that recent developments in genomic techniques could in the future allow the risk of local recurrence among these younger women to be defined more accurately."

Ann Oncol. 2003;14:1617-1622

Reviewed by Gary D. Vogin, MD

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