ASCO--Fewer than half of women with early-stage breast cancer are
treated with breast-conserving lumpectomy, even though up to 75% are
eligible. Almost one-quarter of those who have lumpectomy are not
given radiotherapy to improve local control.
Both problems are largely the result of surgeons failure to
follow the joint guidelines of the American College of Surgeons,
American College of Radiology, and College of American Pathologists,
Monica Morrow, MD, said in her ASCO presentation of a study performed
by the American College of Surgeons and the American College of Radiology.
Dr. Morrow is professor of surgery and director of the Clinical
Breast Cancer Program at Northwestern Universitys Lynn Sage
The guidelines for breast-conserving therapy were developed in 1992
and have been widely disseminated. This study to evaluate guidelines
adherence included data on 17,931 women with stage I or II breast
cancer treated in 1994. Among its main findings:
Only 7,914 (44.1%) had breast-conserving therapy.
About 47% of patients who received breast-conserving therapy
were under age 60, compared with 41% of mastectomy patients (P < .0001).
About 54% of clinical stage I patients had breast-conserving
therapy, compared with 32% of clinical stage II patients and 39% of
patients with no clinical stage data (P < .0001).
About 53% of women with T1 tumors had breast-conserving therapy
vs 33% of those with T2 tumors (P < .0001).
Some 47% of node-negative patients had breast-conserving
therapy vs 32% of node-positive patients (P < .0001).
According to the guidelines, the only contraindications to lumpectomy
plus radiotherapy in early-stage breast cancer are large tumor size,
small breast size in comparison to tumor size, early pregnancy, and
multiple tumors in various sites. Older age, prognosis, and tumor
type are not indications for mastectomy.
Dr. Morrows data show that surgeons are less likely to do
lumpectomies for older patients and are more likely to do
mastectomies if patients have stage II disease, T2 size tumors, or
positive nodes. For example, a 70-year-old woman was one-third less
likely to be treated with breast-conserving therapy than a younger
woman with similar disease.
"These data indicate that physicians still believe that if you
have poorer-prognosis breast cancer, you are better off being treated
with mastectomy," Dr. Morrow commented. Patients with favorable
histologies (tubular, mucinous, intracystic) were more likely to have
had breast conservation than those with other histologies (P < .0001).
Perhaps more important, radiotherapy was given to only 78.6% of
patients treated with lumpectomy. "Of 1,155 patients not
receiving radiotherapy, surgical failure to refer for radiotherapy
accounted for 51.1%, and patient refusal for 15% of cases," Dr.
Surgeons continue to reserve breast-conserving therapy primarily for
patients with favorable breast cancer, in spite of guidelines and
data from randomized trials indicating that age, prognosis, and tumor
type should not be used as selection criteria for local therapy.
"This misunderstanding is a major factor responsible for low
national rates of breast-conserving therapy," Dr. Morrow said.