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Am Fam Physician. 2003;67(6):1362

The National Surgical Adjuvant Breast and Bowel Project recently released an update on a trial of radical mastectomy versus less extensive surgery that showed no difference in survival or breast cancer recurrence after 25 years of follow-up. That trial began before lumpectomy plus adjuvant radiation or chemotherapy became a widely used option for early breast cancer. Fisher and colleagues present 20-year follow-up results from a trial of lumpectomy, with or without irradiation, versus mastectomy in the treatment of breast cancer.

A total of 2,105 women with stage I breast cancer (tumor less than 4 cm, negative nodes) and stage II breast cancer (tumor less than 4 cm, positive nodes) were randomized to either mastectomy, lumpectomy, or lumpectomy with radiation therapy to the affected breast. Axillary nodes were removed in all cases, and women with positive nodes received chemotherapy with melphalan and fluorouracil. Long-term follow-up data were available for 1,851 patients who accepted randomized assignment and had a known nodal status. The mean length of follow-up for the treatment groups was 20 years. About 60 percent of the women were 50 years of age or older, and 62 percent had negative nodes. Patients treated with lumpectomy with no clear surgical margins (10 percent of cases) underwent subsequent mastectomy.

There were no significant differences between the three treatment groups for overall survival, disease-free survival, or the occurrence of breast cancer at a site distant from the original tumor. Local or regional recurrence of breast cancer was lowest in the group treated with lumpectomy plus radiation (8.1 percent), followed by the mastectomy group (14.8 percent), and then by the lumpectomy-alone group (17.5 percent). The rates of breast cancer occurrences at a distant site did not differ significantly among the groups. Distant occurrences of breast cancer were more common (22.4 to 26.0 percent among the three groups) than local or regional recurrences.

The authors conclude that long-term data support the use of lumpectomy followed by radiation therapy as a viable option to mastectomy in cases where clear surgical margins can be achieved with an acceptable cosmetic result.

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