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Mastectomy after Recurrence of Breast Cancer is Recommended

Posted on Oct 17, 2008

If cancer recurs in the same breast after a lumpectomy, mastectomy may be the best next step, researchers here found.

Women who opted for a second lumpectomy for an ipsilateral recurrence had a significantly worse overall survival compared with those who had a mastectomy (P=0.03), Steven Chen, M.D., and Steve Martinez, M.D., of the University of California Davis here, reported in the October issue of the American Journal of Surgery.

Five-year survivals after a cancer recurrence were 67% and 78% for the lumpectomy and mastectomy groups, respectively. Ten-year survivals were 57% and 62%, respectively.

"As therapy for breast cancer becomes more targeted and researchers come closer to identifying those factors that make some breast cancers more aggressive than others, we may have the option of recommending second and even third lumpectomies in select cases in the future," Dr. Martinez said.

"Until then," he said, "mastectomy remains the best option for women experiencing a same-breast recurrence of their breast cancer."

Increased rates of breast cancer survival and a decreased emphasis on mastectomy have combined to increase the opportunity for recurrence of the cancer, according to the researchers.

Because many women who have breast-conservation surgery for a first breast cancer decide to use the same treatment for a recurrence, Drs. Chen and Martinez set out to evaluate whether the decision had any effect on survival.

They identified 747 women who had had lumpectomies followed by radiation and had then been diagnosed with an ipsilateral breast cancer recurrence using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database.

Of those, 24% decided to have another lumpectomy. Lumpectomy patients were significantly older than those who had a mastectomy (64 versus 60, P=0.03).

A significantly greater, but still small, proportion of lumpectomy patients received radiation therapy after their surgery (21% versus 5%, P<0.001).

"We were surprised by the number of patients undergoing lumpectomy alone as treatment for second breast cancers," Drs. Chen and Martinez said. "Certainly, prior data on initial breast cancers would seem to indicate that there are unacceptable recurrence rates when lumpectomy is not paired with radiation."

In a multivariate analysis controlling for age, sex, tumor stage, hormone-receptor status, use of radiation, and disease-free interval, patients who opted for a mastectomy had a survival advantage of 50% (HR 0.5, 95% CI 0.3 to 0.8, P=0.003).

Aside from the use of lumpectomy, other significant predictors of worse overall survival were higher T stage (P<0.001), higher grade (P=0.05), negative estrogen-receptor status (P<0.001), and older age (P=0.001).

According to the researchers, lumpectomy has overtaken mastectomy as the most common breast cancer surgery over the past 30 years.

An increasing number of women must now decide what to do in case of a recurrence, they said.

"Traditional teaching on this has been fairly straightforward: mastectomy is the preferred option," they said. "However, advances in systemic therapy, and the general preference expressed by American women for breast conservation have challenged this teaching."

"Still," they continued, "mastectomy clearly provides the maximal risk reduction in the recurrence of breast cancer because it leaves the least amount of breast tissue behind."

The authors acknowledged some limitations of the study, including the possible miscoding of data, the lack of information on adjuvant chemotherapy or hormonal therapy and margin status, and the use of overall survival as an endpoint rather than disease-specific survival.

"Despite these limitations," they said, "these data bring about an alarming set of observations. The number of patients receiving therapy that many would consider to be suboptimal is significant and increasing. Although breast conservation has become the default procedure for many breast surgeons, its use in the recurrent setting should not be recommended as equivalent to mastectomy at this time."

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