Early Breast Cancer. Treatments
The real debate is, do all women need radiation therapy? Even though I am a radiation oncologist, sometimes I say probably this patient’s won’t benefit. There is a certain morbidity to radiation, it’s very expensive, one must question whether small low grade tumors, especially if you are considering adding tamoxifen need to have radiation therapy for improved local control. This is the kind of ductal carcinoma in situ I am talking about. I had to circle in red because you can barely see it. It’s a 3 mm low grade ductal carcinoma in situ, excised with 2 cm of normal margin. Does that patient really need radiation therapy? Some physicians in California, tried to develop a retrospective prognostic index, what they did is they looked at their thousands of patient’s they had treated for the last 20 years in a nonrandomized way and they decided that tumor size nuclear grade, the presence of necrosis and the margin width could kind of be juggled into a grid to help you decide which patient’s may or may not benefit from radiation therapy. So they developed a score, and you may see these scores on your pathology reports because they are becoming increasingly used to help you determine the clinical significance of the ductal carcinoma in situ. The size is given a score of 1, 2, 3, based on how many mm it is, the margin is given a score of 1, 2, 3, based on if it’s a little bit of a margin, or a great big margin and the grade is 1, 2, 3, so the lower the score, the better, the higher the score, the worst. Then they basically add up your scores and they help you decide a treatment option. If you have a score of 3 or 4, they show that excision alone will allow about a 90% long term local control in the breast without radiation, a 5, 6, or 7 indicates that radiation therapy gives the best chance in addition to excision with local control, and if you have an 8 or 9, no on would disagree that a simple mastectomy is appropriate.
This is a histograph of an infiltrating ductal carcinoma and you can see that this is much different than ductal carcinoma in situ. Now we have the stroma of the breast infiltrated by these strands of very malignant cells still forming small ducts.
Infiltrating ductal carcinoma is treated much like ductal carcinoma in situ with a few exceptions. You again start with bilateral mastectomy, biopsy, most of the time a post mastectomy mammogram, postbiopsy mammogram is indicated. A patient is then treated by either a modified radical mastectomy which includes dissection and chest wall radiation therapy is becoming increasingly used for premenopausal women based on the risk factors at the time of mastectomy. The vast majority of patient’s are treated with breast preservation in which the axillary nodes are removed either by sentinel node biopsy and/or level 1 and 2 dissection and excision of the tumor is done with negative margins and then the breast is radiated. You think breast preservation is new, this is from 1947. This was Jeffrey Keats who first tried to preserve breasts by putting radium needles into the breast and the regional lymphatics. As painful as that looks, it was highly successful and his results were reported to be the same as Sir Halstead who was the ruling guru of radical mastectomy of the day. His work stopped not because it was ineffective but because the war prevented the continued use of radium needles and it wasn’t until many years later that others took up the concept of breast preservation. Breast preservation has now been well established in over randomized trials comparing modified radical mastectomy to excision and radiation therapy. This is just a brief slide of the different series, the yellow is the modified radical mastectomy and the red is breast preservation. This is a graft of local recurrence. Local recurrence with breast preservation is about three to 19% at 10 years. Most important, there is no difference in survival, whether a woman has her breast removed or is allowed to keep her breast.