Ten-Year Results of a Comparison of Conservation with Mastectomy in the Treatment of Stage I and II Breast Cancer
Joan A. Jacobson, M.D., David N. Danforth, M.D., Kenneth H. Cowan, M.D., Teresa d'Angelo, B.S., Seth M. Steinberg, Ph.D., Lori Pierce, M.D., Marc E. Lippman, M.D., Allen S. Lichter, M.D., Eli Glatstein, M.D., and Paul Okunieff, M.D.
Background Breast-conservation therapy for early-stage breastcancer is now an accepted treatment, but there is still controversyabout its comparability with mastectomy. Between 1979 and 1987,the National Cancer Institute conducted a randomized, single-institutiontrial comparing lumpectomy, axillary dissection, and radiationwith mastectomy and axillary dissection for stage I and II breastcancer. We update the results of that trial after a median potentialfollow-up of 10.1 years.
Methods Two hundred forty-seven patients with clinical stageI and II breast cancer were randomly assigned to undergo eithermodified radical mastectomy or lumpectomy, axillary dissection,and radiation therapy. The 237 patients who actually underwentrandomization have been followed for a median of 10.1 years.The primary end points were overall survival and disease-freesurvival.
Results At 10 years overall survival was 75 percent for thepatients assigned to mastectomy and 77 percent for those assignedto lumpectomy plus radiation (P = 0.89). Disease-free survivalat 10 years was 69 percent for the patients assigned to mastectomyand 72 percent for those assigned to lumpectomy plus radiation(P = 0.93). The rate of local regional recurrence at 10 yearswas 10 percent after mastectomy and 5 percent after lumpectomyplus radiation (P = 0.17) after recurrences successfully treatedby mastectomy were censored from the analysis.
Conclusions In the management of stage I and II breast cancer,breast conservation with lumpectomy and radiation offers resultsat 10 years that are equivalent to those with mastectomy.
Conservative therapy in the management of early-stage carcinomaof the breast, once controversial, is now an established alternativeto mastectomy. Several randomized studies in Europe and NorthAmerica that address various aspects of conservative treatmentof breast cancer have accumulated a median of 10 or more yearsof follow-up.1,2,3,4,5 All of them confirm that breast-conservinglocal therapies and more radical surgical therapies yield similarrates of survival. (However, the largest of these randomizedclinical trials, the National Surgical Adjuvant Breast Project[NSABP] B-06 trial, was affected by an episode of misconduct,6and reanalysis of this trial after expunging of fraudulent dataand extensive auditing has not yet been published.)
The National Cancer Institute's early breast-cancer trial comparinglumpectomy, axillary dissection, and radiation with modifiedradical mastectomy has now accumulated a median potential follow-upof 10.1 years (median potential follow-up is defined here asthe median follow-up if all patients had survived). This paperupdates our previous report, which was based on a median of5.7 years of follow-up,7,8 and compares findings with thoseof other randomized trials for conservative management of early-stagebreast cancer. Our trial was conducted separately from the otherrandomized North American trial — the NSABP B-06 trial— and differed from it somewhat in terms of eligibilityand design. The updated results of our single-institution randomizedtrial continue to show no significant difference in overallsurvival or disease-free survival between the two treatmentgroups.
Methods
Patients
Previous reports7,8 of this trial included a detailed descriptionof the study design, eligibility requirements, radiation andsurgical techniques, and statistical methods and a comparisonof the characteristics of the patients in each treatment group.Briefly, between July 1979 and December 1987, 247 patients givena diagnosis of clinical stage I or II (T1 or T2, which includedtumors with diameters of up to 5 cm; N0 or N1; M0) invasivecarcinoma of the breast were enrolled in the trial. Eligiblepatients had no prior cancer, no evidence of metastatic disease,a single invasive lesion without multiple palpable or mammographicallysuspicious areas, no concurrent or previous occurrence of cancerin the contralateral breast, and no evidence of Paget's disease,and were not pregnant or breast-feeding. A comparison of thepatients' characteristics showed no significant differencesbetween the two groups.7 Patients were stratified accordingto age (<50 years vs. >50 years) and clinical nodal status(positive vs. negative). Patients were randomly assigned toundergo total mastectomy with complete axillary dissection orto follow a program of breast conservation consisting of excisionalbiopsy, complete axillary dissection, and radiation therapy.Fully informed consent was obtained from each patient beforerandomization. Ten patients (six assigned to mastectomy andfour to breast conservation) declined to undergo their assignedtreatment; they were treated elsewhere and not evaluated further.Thus, 237 patients remained in the study: 116 in the mastectomygroup and 121 in the breast-conservation group. These patientswere previously analyzed in June 1989 after a median follow-upof 68 months. The present analysis, with data updated throughNovember 1993, extends the median potential follow-up to 121months, with a range of 71 to 172 months (5.9 to 14.3 years).Three patients were lost to follow-up, and data on them werecensored after 4.8, 6.2, and 8.8 years of follow-up. They allwere disease-free at last known follow-up.
Techniques
Patients randomly assigned to undergo mastectomy underwent aPatey modified radical mastectomy with a complete axillary dissection(level I to III).9 The chest wall was not irradiated postoperatively.Optional breast reconstruction was elected by 68 of the 116patients (59 percent). Patients randomly assigned to breastconservation were required to have all gross tumor removed butwere not required to have negative margins on microscopy. Asecond excision was permitted when initial surgery was thoughtto have been incomplete. One patient in the breast-conservationgroup was thought to have gross tumor remaining after a secondexcision and underwent a mastectomy. She is analyzed in thebreast-conservation group. Patients underwent a complete axillarydissection (level I to III) through a separate axillary incision.
Radiation consisted of an isodose of 4500 to 5040 cGy to thewhole breast, given in fractions of 180 cGy five days per week,with treatment plans including at least two off-central axiscuts. In patients with pathologically positive axillary nodes,4500 to 5040 cGy was also directed to an anterior supraclavicularfield at a depth of 3 cm over a period of 5 to 5.5 weeks. Anattempt was made to include the internal mammary nodes in patientswith positive axillae or medial lesions by extending the tangentfield across the midline. The internal mammary nodes were assumedto be covered if the pleurosternal junction was covered. Thepleurosternal junction was located with ultrasonography or computedtomography, one of which was used in the planning of all treatment.10After 1981, dose plans included correction factors for lungdensity.11 The axilla was not treated. The tumor bed receiveda booster dose of radiation (1500 to 2000 cGy) through the useof either iridium-92 implants (81 percent of patients) or anelectron beam (19 percent of patients).
All patients with positive nodes received adjuvant chemotherapyconsisting of cyclophosphamide (Cytoxan) and doxorubicin (Adriamycin).Initially, chemotherapy was given for 1 year in 28-day cyclesconsisting of doxorubicin at a dose of 30 mg per square meterof body-surface area intravenously on day 1 and cyclophosphamideat a dose of 150 mg per square meter orally on days 3 through6.12 The dose of cyclophosphamide was increased to 200 mg persquare meter in 1983. In 1985, the dose of doxorubicin was increasedto 40 mg per square meter, the cycle length was decreased to21 days, and the duration of chemotherapy was decreased to 6months (nine cycles). After 1985, tamoxifen (Nolvadex), at adose of 20 mg twice per day orally, was given for five yearsto postmenopausal node-positive patients.
Statistical Analysis
The probability of survival and disease-free survival as a functionof time was calculated according to the Kaplan–Meier method.13Overall survival was measured from the date of randomizationuntil death or the last follow-up visit. Disease-free survivaland local or regional recurrence were measured from the dateof randomization until recurrence or the last follow-up visit;however, patients who had an isolated recurrence of cancer withinthe breast that was successfully treated by mastectomy wereconsidered to be disease-free as of the date of the last follow-upvisit. Cancer in the contralateral breast was not consideredan event; however, any distant or local or regional recurrencesafter the initial treatment for contralateral-breast cancerwere ascribed to the initial breast cancer. The significanceof differences between pairs of actuarial curves was determinedwith the Mantel–Haenszel test.14 All P values are two-tailed.
Results
After a median potential follow-up of 10.1 years (range, 5.9to 14.3), disease-free survival and overall survival continueto be similar in the two treatment groups (Figure 1A and Figure 1B).Overall survival at 10 years was 75 percent for patientsassigned to mastectomy and 77 percent for patients assignedto lumpectomy plus radiation (P = 0.89), yielding a 2 percentdifference in survival favoring lumpectomy plus radiation (95percent confidence interval ranging from 9 percent favoringmastectomy to 14 percent favoring radiation). Disease-free survivalat 10 years (Figure 1B) was 69 percent for patients assignedto mastectomy and 72 percent for patients assigned to lumpectomyplus radiation (P = 0.93), yielding a 3 percent difference favoringlumpectomy plus radiation (95 percent confidence interval rangingfrom 9 percent favoring mastectomy to 16 percent favoring radiation).Table 1 shows the cumulative incidence of events in each group.
Figure 1. Overall Survival (Panel A) and Disease-free Survival (Panel B) in the Two Groups.
Tick marks indicate the lengths of follow-up for patients who had not died (Panel A) or had a recurrence of disease (Panel B). Wider bars represent overlapping tick marks.
Table 1. Incidence of Events in the Two Treatment Groups.
Local or regional recurrences were defined as recurrences inthe ipsilateral supraclavicular, axillary, or internal mammarynodal regions; chest-wall disease; or inoperable recurrencewithin the breast. Recurrence within the breast that was successfullytreated by mastectomy was not considered a local or regionalrecurrence unless it was followed by a further local or regionalevent. The rate of local or regional recurrence as an isolatedfirst event was 4 percent for the mastectomy group and 4 percentfor the group assigned to lumpectomy plus radiation (P = 0.94;95 percent confidence interval ranging from 5 percent favoringradiation to 6 percent favoring mastectomy). However, the rateof local or regional recurrence as any component of a firstevent, whether isolated or with concomitant distant disease,was 10 percent for the mastectomy group and 5 percent for thegroup assigned to lumpectomy plus radiation (P = 0.17; 95 percentconfidence interval ranging from 2 percent favoring radiationto 11 percent favoring mastectomy). Figure 2A and Figure 2Bdepicts these results.
Figure 2. Local or Regional Recurrences as Isolated First Events (Panel A) or as Any Component of a First Event (Panel B) in the Two Treatment Groups.
Data were censored on patients with recurrences confined to the ipsilateral breast and successfully treated. Tick marks indicate follow-up times for patients who had not had recurrences.
In 10 patients in the mastectomy group, local or regional disease,either alone (4 patients) or with distant disease (6 patients),was the first event. In all 10 patients, salvage therapy involvingsurgery, radiation, or chemotherapy or hormonal treatment wasunsuccessful, and distant disease ultimately developed.
At 10 years the actuarial risk of a recurrence confined to theipsilateral breast in the group that underwent lumpectomy plusradiation was 18 percent (Figure 3). There were 19 patientswith such recurrences, and 1 with concurrent distant metastases.The rate of tumor recurrence within the ipsilateral breast wasnot significantly associated with any of the stratificationfactors, including age, tumor stage, and nodal status, or withany of the other factors considered, including the center performingthe initial biopsy (National Institutes of Health Clinical Centervs. elsewhere), the need for a second excision, and the estrogen-receptorstatus. The risk of recurrence within the breast was not higherin patients reported to have had an incomplete initial excisionor in patients who required a second excision than in patientswho did not require a second excision. The number of patientsavailable for evaluation of any possible recurrence factor wassmall. Initial salvage mastectomy was possible in 18 of the19 patients with recurrence confined to the ipsilateral breast.Since mastectomy, no further local or regional disease has occurredin 15 of these 18 patients (83 percent), with additional follow-upranging from 3 months to 9.9 years. In 3 of the 18, recurrentlocal or regional disease developed, followed by distant disease.In the 19th patient, who presented with inflammatory diseaseat the time of recurrence, chemotherapy and hormonal therapywere soon followed by distant metastases. In three patients,distant disease developed after salvage mastectomy without evidenceof further local or regional disease 50, 69, and 72 months aftersalvage mastectomy. One of these three patients also had anintervening node-positive (24 of 24 nodes positive) cancer ofthe contralateral breast 18 months after salvage mastectomyand 32 months before the development of distant disease.
Figure 3. Actuarial Risk of Recurrence Confined to the Ipsilateral Breast among 121 Patients Assigned to Lumpectomy plus Radiation.
Nineteen patients had a recurrence (16 percent). Tick marks indicate follow-up times for patients without recurrences.
Tumor stage and spread to axillary lymph nodes were the onlysignificant prognostic factors for disease-free survival. Therewere 126 patients with pathological T1 tumors, 103 patientswith T2 tumors, and 8 patients whose tumor size was unrecorded.The disease-free survival at 10 years was 81 percent for womenwith T1 tumors and 58 percent for women with T2 tumors (P <0.001). There were 141 patients with pathologically node-negativebreast cancer and 96 with node-positive cancer; in these twosubgroups disease-free survival at 10 years was 82 percent and54 percent, respectively (P < 0.001). When the patients weredivided according to the tumor stage and nodal status, therewere no significant differences in disease-free survival betweenthe two treatment groups.
Patients were stratified according to whether they were youngerthan 50 years of age or 50 years of age or older. No age-relateddifferences were observed within each treatment group. No significantdifference was detected in disease-free survival between thetwo age groups (P = 0.64). The absolute rates of recurrenceat 10 years were 27 percent for patients younger than 50 years(30 of 113) and 30 percent for patients 50 years or older (37of 124). Estrogen-receptor status, which was known only forabout two thirds of the patients, did not appear to influencedisease-free survival, either within treatment groups or overall.
Discussion
The results of this trial after a median potential follow-upof 10.1 years continue to show no difference in the outcomebetween breast-conservation therapy and mastectomy. This single-institutiontrial corroborates the results of five other similar randomizedtrials (Table 2).1,2,3,4,5 The follow-up periods in these sixtrials now range from 6 to 13 years. The criteria for inclusionvaried among the trials, as did specific details of treatment,including radiation technique, surgical technique, and chemotherapyregimen. Nevertheless, the results of all these studies demonstratethe efficacy of breast-sparing surgery plus radiation and theequivalence of survival after either breast-sparing surgeryplus radiation or mastectomy. Eligibility criteria in the NationalCancer Institute trial were broader than in many of the othertrials, including the only other North American trial, the NSABPB-06.5,15 All patients with T1 or T2 tumors (tumors up to 5cm in diameter) were potentially eligible for this trial, incontrast to the NSABP B-06 trial, which excluded women whosetumors measured 4 cm or more, and two of the European trials,which excluded women with tumors measuring 2 cm or more. Eightpercent of the patients (10 of 116 in the mastectomy group and8 of 121 in the group that underwent lumpectomy plus radiation)had tumors that exceeded 4 cm in diameter. Gross tumor resectionwas required in the National Cancer Institute trial, and a secondexcision to achieve this was allowed. In only one patient wasa second attempt at gross tumor removal unsuccessful. In theNSABP B-06 trial, specimens with initially negative marginson pathological examination were required, and 10 percent ofthe patients randomly assigned to breast-conservation therapyactually underwent mastectomy because of histologically positivemargins.5
Table 2. Comparison of Randomized Trials of Breast-Conservation Therapy.
Recently, concern has been expressed about both the long-termoutcome of patients who have undergone salvage mastectomy forrecurrences within the breast, and the possible increased riskof development of distant disease.16,17,18,19 The rate of recurrenceof cancer confined to the breast in the group assigned to lumpectomyplus radiation in the NSABP B-06 trial was 12 percent at 9 years20and has ranged from 8 to 20 percent at 10 to 15 years in otherstudies.21,22,23 In our trial, the actuarial rate of recurrenceof cancer confined to the ipsilateral breast at 10 years was18 percent. Three months to 9.9 years after salvage mastectomy,12 of the 19 patients with such recurrences had no further evidenceof disease. The projected rate of disease-free survival at 10years for these 19 patients is 67 percent — a rate thatis not significantly different from that for all women assignedto lumpectomy plus radiation. Moreover, the risk of local orregional failure at 10 years in the group that underwent mastectomywas 10 percent. All 10 of the patients in this group with localor regional failure had either concurrent or subsequent distantdisease and none underwent successful salvage therapy, whereasdistant metastases developed in only 8 of the 20 patients witha recurrence of cancer within the breast after breast-conservationtherapy.
The 10-year follow-up of the National Cancer Institute trialconfirms that the outcome of treatment for women with stageI or II breast cancer does not depend on the nature of the localtreatment of the breast, provided the treatment is adequate.Mastectomy and lumpectomy plus radiation are both excellentlocal therapies, with equivalent survival rates. An importantcorollary of these results is that no new putative predictorof increased rates of local recurrence, whether it be a biologicmarker or a new sensitive imaging technology, if used to alterdecisions regarding local treatment, can be expected to affectthe risk of distant disease or the likelihood of survival. Aftercareful evaluation and discussion with her surgeon, radiationoncologist, and medical oncologist, it is the patient who mustdecide which of the two local therapies to receive. We believethat improvements in survival can only arise from improvementsin the early detection of breast cancer before disseminationhas occurred or from improvements in adjuvant therapy.
We are indebted to Drs. Bruce Chabner and Dwight Kaufman fortheir critical comments and many helpful suggestions.
Source Information
From the Radiation Oncology Branch (J.A.J., P.O.), Surgery Branch (D.N.D.), Medicine Branch (K.H.C.), Biostatistics and Data Management Section (S.M.S.), and Cancer Nursing Service (T.D.) of the Clinical Oncology Program, Division of Cancer Treatment, National Cancer Institute, Bethesda, Md.; the Department of Radiation Oncology, University of Michigan Medical Center, Ann Arbor (L.P., A.S.L.); Lombardi Cancer Center, Georgetown University Hospital, Washington, D.C. (M.E.L.); and the Department of Radiation Oncology, Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas (E.G.).
Address reprint requests to Dr. Jacobson at the Radiation Oncology Branch, National Cancer Institute, Bldg. 10, Rm. B3-B69, Bethesda, MD 20892.
References
van Dongen JA, Bartelink H, Fentiman IS, et al. Randomized clinical trial to assess the value of breast-conserving therapy in stage I and II breast cancer: EORTC 10801 trial. Monogr Natl Cancer Inst 1992;11:15-8.
Veronesi U, Banfi A, Salvadori B, et al. Breast conservation is the treatment of choice in small breast cancer: long-term results of a randomized trial. Eur J Cancer 1990;26:668-670.
Sarrazin D, Le MG, Arriagada R, et al. Ten-year results of a randomized trial comparing a conservative treatment to mastectomy in early breast cancer. Radiother Oncol 1989;14:177-184. [CrossRef][Medline]
Blichert-Toft M, Rose C, Andersen JA, et al. Danish randomized trial comparing breast conservation therapy with mastectomy: six years of life-table analysis. Monogr Natl Cancer Inst 1992;11:19-25.
Fisher B, Redmond C, Poisson R, et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989;320:822-828. [Abstract]
Angell M, Kassirer JP. Setting the record straight in the breast-cancer trials. N Engl J Med 1994;330:1448-1450. [Free Full Text]
Lichter AS, Lippman ME, Danforth DN Jr, et al. Mastectomy versus breast-conserving therapy in the treatment of stage I and II carcinoma of the breast: a randomized trial at the National Cancer Institute. J Clin Oncol 1992;10:976-983. [Abstract]
Straus K, Lichter A, Lippman M, et al. Results of the National Cancer Institute early breast cancer trial. Monogr Natl Cancer Inst 1992;11:27-32.
Danforth DN Jr, Findlay PA, McDonald HD, et al. Complete axillary lymph node dissection for stage I-II carcinoma of the breast. J Clin Oncol 1986;4:655-662. [Free Full Text]
Lichter AS, Fraass BA, Fredrickson HA, Roberson PL, van de Geijn J. Computed tomography in treatment planning: primary breast cancer. In: Ling CC, Rogers CC, Morton RJ, eds. Computed tomography in radiation therapy. New York: Raven Press, 1983:99-107.
Fraass BA, Lichter AS, McShan DL, et al. The influence of lung density corrections on treatment planning for primary breast cancer. Int J Radiat Oncol Biol Phys 1988;14:179-190. [Medline]
Lippman ME, Edwards BK, Findlay P, et al. Influence of definitive radiation therapy for primary breast cancer on ability to deliver adjuvant chemotherapy. Monogr Natl Cancer Inst 1986;1:99-104.
Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457-81.
Mantel N. Chi-square tests with one degree of freedom: extensions of the Mantel-Haenszel procedure. J Am Stat Assoc 1963;58:690-700.
Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985;312:665-673. [Abstract]
Abner AL, Recht A, Eberlein T, et al. Prognosis following salvage mastectomy for recurrence in the breast after conservative surgery and radiation therapy for early-stage breast cancer. J Clin Oncol 1993;11:44-48. [Abstract]
Kurtz JM, Amalric R, Delouche G, Pierquin B, Roth J, Spitalier JM. The second ten years: long-term risks of breast conservation in early breast cancer. Int J Radiat Oncol Biol Phys 1987;13:1327-1332. [Medline]
Chauvet B, Reynaud-Bougnoux A, Calais G, et al. Prognostic significance of breast relapse after conservative treatment in node-negative early breast cancer. Int J Radiat Oncol Biol Phys 1990;19:1125-1130. [Medline]
Stotter A, Atkinson EN, Fairston BA, McNeese M, Oswald MJ, Balch CM. Survival following locoregional recurrence after breast conservation therapy for cancer. Ann Surg 1990;212:166-172. [Medline]
Fisher B, Anderson S, Fisher ER, et al. Significance of ipsilateral breast tumor recurrence after lumpectomy. Lancet 1991;338:327-331. [CrossRef][Medline]
Stotter AT, McNeese MD, Ames FC, Oswald MJ, Ellerbroek NA. Predicting the rate and extent of locoregional failure after breast conservation therapy for early breast cancer. Cancer 1989;64:2217-2225. [CrossRef][Medline]
Boyages J, Recht A, Connolly JL, et al. Early breast cancer: predictors of breast recurrence for patients treated with conservative surgery and radiation therapy. Radiother Oncol 1990;19:29-41. [CrossRef][Medline]
Fowble BL, Solin LJ, Schultz DJ, et al. Ten year results of conservative surgery and irradiation for stage I and II breast cancer. Int J Radiat Oncol Biol Phys 1991;21:269-277. [Medline]
Godinez, J., Gombos, E. C., Chikarmane, S. A., Griffin, G. K., Birdwell, R. L.
(2008). Breast MRI in the Evaluation of Eligibility for Accelerated Partial Breast Irradiation. Am. J. Roentgenol.
191: 272-277
[Abstract][Full Text]
Yang, S. H., Yang, K. H., Li, Y. P., Zhang, Y. C., He, X. D., Song, A. L., Tian, J. H., Jiang, L., Bai, Z. G., He, L. F., Liu, Y. L., Ma, B.
(2008). Breast conservation therapy for stage I or stage II breast cancer: a meta-analysis of randomized controlled trials. Ann Oncol
19: 1039-1044
[Abstract][Full Text]
Rakovitch, E., Pignol, J.-P., Hanna, W., Narod, S., Spayne, J., Nofech-Mozes, S., Chartier, C., Paszat, L.
(2007). Significance of Multifocality in Ductal Carcinoma In Situ: Outcomes of Women Treated With Breast-Conserving Therapy. JCO
25: 5591-5596
[Abstract][Full Text]
Morrogh, M., Borgen, P. I., King, T. A.
(2007). The Importance of Local Control in Early-Stage Breast Cancer: A Historical Review and a Discussion of Ongoing Issues. Ann. Surg. Oncol.
14: 3310-3320
[Full Text]
Haid, A., Knauer, M., Dunzinger, S., Jasarevic, Z., Koberle-Wuhrer, R., Schuster, A., Toeppker, M., Haid, B., Wenzl, E., Offner, F.
(2007). Intra-operative Sonography: A Valuable Aid During Breast-Conserving Surgery for Occult Breast Cancer. Ann. Surg. Oncol.
14: 3090-3101
[Abstract][Full Text]
O'Sullivan, M. J., Li, T., Freedman, G., Morrow, M.
(2007). The Effect of Multiple Reexcisions on the Risk of Local Recurrence After Breast Conserving Surgery. Ann. Surg. Oncol.
14: 3133-3140
[Abstract][Full Text]
Olson, T. P., Harter, J., Munoz, A., Mahvi, D. M., Breslin, TM.
(2007). Frozen Section Analysis for Intraoperative Margin Assessment During Breast-Conserving Surgery Results in Low Rates of Re-excision and Local Recurrence. Ann. Surg. Oncol.
14: 2953-2960
[Abstract][Full Text]
Bartelink, H., Horiot, J.-C., Poortmans, P. M., Struikmans, H., Van den Bogaert, W., Fourquet, A., Jager, J. J., Hoogenraad, W. J., Oei, S. B., Warlam-Rodenhuis, C. C., Pierart, M., Collette, L.
(2007). Impact of a Higher Radiation Dose on Local Control and Survival in Breast-Conserving Therapy of Early Breast Cancer: 10-Year Results of the Randomized Boost Versus No Boost EORTC 22881-10882 Trial. JCO
25: 3259-3265
[Abstract][Full Text]
Cabioglu, N., Hunt, K. K., Sahin, A. A., Kuerer, H. M., Babiera, G. V., Singletary, S. E., Whitman, G. J., Ross, M. I., Ames, F. C., Feig, B. W., Buchholz, T. A., Meric-Bernstam, F.
(2007). Role for Intraoperative Margin Assessment in Patients Undergoing Breast-Conserving Surgery. Ann. Surg. Oncol.
14: 1458-1471
[Abstract][Full Text]
Sanders, M. E., Scroggins, T., Ampil, F. L., Li, B. D.
(2007). Accelerated Partial Breast Irradiation in Early-Stage Breast Cancer. JCO
25: 996-1002
[Abstract][Full Text]
Martin, M. A., Meyricke, R., O'Neill, T., Roberts, S.
(2007). Breast-Conserving Surgery Versus Mastectomy for Survival from Breast Cancer: the Western Australian Experience. Ann. Surg. Oncol.
14: 157-164
[Abstract][Full Text]
Klimberg, V. S., Kepple, J., Shafirstein, G., Adkins, L., Henry-Tillman, R., Youssef, E., Brito, J., Talley, L., Korourian, S.
(2006). eRFA: Excision Followed by RFA--a New Technique to Improve Local Control in Breast Cancer. Ann. Surg. Oncol.
13: 1422-1433
[Abstract][Full Text]
Wapnir, I. L., Anderson, S. J., Mamounas, E. P., Geyer, C. E. Jr, Jeong, J.-H., Tan-Chiu, E., Fisher, B., Wolmark, N.
(2006). Prognosis After Ipsilateral Breast Tumor Recurrence and Locoregional Recurrences in Five National Surgical Adjuvant Breast and Bowel Project Node-Positive Adjuvant Breast Cancer Trials. JCO
24: 2028-2037
[Abstract][Full Text]
Bouknight, R. R., Bradley, C. J., Luo, Z.
(2006). Correlates of Return to Work for Breast Cancer Survivors. JCO
24: 345-353
[Abstract][Full Text]
Cykert, S., Phifer, N., Hansen, C.
(2004). Tamoxifen for Breast Cancer Prevention: A Framework for Clinical Decisions. Obstet Gynecol
104: 433-442
[Abstract][Full Text]
Richards, G. M., Berson, A. M., Rescigno, J., Sanghavi, S., Siegel, B., Axelrod, D., Bernik, S., Scarpinato, V., Mills, C.
(2004). Acute Toxicity of High-Dose-Rate Intracavitary Brachytherapy With the MammoSite Applicator in Patients With Early-Stage Breast Cancer. Ann. Surg. Oncol.
11: 739-746
[Abstract][Full Text]
Vargas, H. I., Khalkhali, I., Gonzalez, K. D., Eldrageely, K., Burla, M., Vargas, M. P.
(2004). Use of Preoperative Breast Ultrasonography for Mapping of Breast Cancer Extent Improves Resection Margins During Breast Conservation Surgery. Arch Surg
139: 863-869
[Abstract][Full Text]
Vinh-Hung, V., Verschraegen, C.
(2004). Breast-Conserving Surgery With or Without Radiotherapy: Pooled-Analysis for Risks of Ipsilateral Breast Tumor Recurrence and Mortality. JNCI J Natl Cancer Inst
96: 115-121
[Abstract][Full Text]
Weitzel, J. N., McCaffrey, S. M., Nedelcu, R., MacDonald, D. J., Blazer, K. R., Cullinane, C. A.
(2003). Effect of Genetic Cancer Risk Assessment on Surgical Decisions at Breast Cancer Diagnosis. Arch Surg
138: 1323-1328
[Abstract][Full Text]
Arriagada, R., Le, M. G., Guinebretiere, J.-M., Dunant, A., Rochard, F., Tursz, T.
(2003). Late local recurrences in a randomised trial comparing conservative treatment with total mastectomy in early breast cancer patients. Ann Oncol
14: 1617-1622
[Abstract][Full Text]
Hirsch, A.
(2003). Integrative Tumor Board: Recurrent Breast Cancer or New Primary?. Integr Cancer Ther
2: 272-276
Kattlove, H., Winn, R. J.
(2003). Ongoing Care of Patients After Primary Treatment for Their Cancer. CA Cancer J Clin
53: 172-196
[Abstract][Full Text]
Tang, P., Hajdu, S. I., Conte, C. C., Filardi, D. A.
(2003). Incidental Finding of Mammary Carcinoma in Lumpectomy Specimens. Annals of Clinical & Laboratory Science
33: 23-31
[Abstract][Full Text]
Fisher, B., Anderson, S., Bryant, J., Margolese, R. G., Deutsch, M., Fisher, E. R., Jeong, J.-H., Wolmark, N.
(2002). Twenty-Year Follow-up of a Randomized Trial Comparing Total Mastectomy, Lumpectomy, and Lumpectomy plus Irradiation for the Treatment of Invasive Breast Cancer. NEJM
347: 1233-1241
[Abstract][Full Text]
Freedman, G. M., Hanlon, A. L., Fowble, B. L., Anderson, P. R., Nicoloau, N.
(2002). Recursive Partitioning Identifies Patients at High and Low Risk for Ipsilateral Tumor Recurrence After Breast-Conserving Surgery and Radiation. JCO
20: 4015-4021
[Abstract][Full Text]
Hansen, N. M., Grube, B. J., Giuliano, A. E.
(2002). The Time Has Come to Change the Algorithm for the Surgical Management of Early Breast Cancer. Arch Surg
137: 1131-1135
[Abstract][Full Text]
Morrow, M., Strom, E. A., Bassett, L. W., Dershaw, D. D., Fowble, B., Harris, J. R., O'Malley, F., Schnitt, S. J., Singletary, S. E., Winchester, D. P.
(2002). Standard for the Management of Ductal Carcinoma In Situ of the Breast (DCIS). CA Cancer J Clin
52: 256-276
[Abstract][Full Text]
Morrow, M., Strom, E. A., Bassett, L. W., Dershaw, D. D., Fowble, B., Giuliano, A., Harris, J. R., O'Malley, F., Schnitt, S. J., Singletary, S. E., Winchester, D. P.
(2002). Standard for Breast Conservation Therapy in the Management of Invasive Breast Carcinoma. CA Cancer J Clin
52: 277-300
[Abstract][Full Text]
Punglia, R. S., Harris, J. R.
(2002). Integrating Surgery and Radiotherapy to Reduce Toxicity While Maintaining Local Control for Breast Cancer: A Fine Balance. Ann. Surg. Oncol.
9: 526-528
[Full Text]
Helvie, M. A., Bailey, J. E., Roubidoux, M. A., Pass, H. A., Chang, A. E., Pierce, L. J., Wilkins, E. G.
(2002). Mammographic Screening of TRAM Flap Breast Reconstructions for Detection of Nonpalpable Recurrent Cancer. Radiology
224: 211-216
[Abstract][Full Text]
Janni, W., Rjosk, D., Dimpfl, Th., Haertl, K., Strobl, B., Hepp, F., Hanke, A., Bergauer, F., Sommer, H.
(2001). Quality of Life Influenced by Primary Surgical Treatment for Stage I-III Breast Cancer--Long-Term Follow-Up of a Matched-Pair Analysis. Ann. Surg. Oncol.
8: 542-548
[Abstract][Full Text]
Vicini, F. A., Baglan, K. L., Kestin, L. L., Mitchell, C., Chen, P. Y., Frazier, R. C., Edmundson, G., Goldstein, N. S., Benitez, P., Huang, R. R., Martinez, A.
(2001). Accelerated Treatment of Breast Cancer. JCO
19: 1993-2001
[Abstract][Full Text]
Voogd, A. C., Nielsen, M., Peterse, J. L., Blichert-Toft, M., Bartelink, H., Overgaard, M., van Tienhoven, G., Andersen, K. W., Sylvester, R. J., van Dongen, J. A.
(2001). Differences in Risk Factors for Local and Distant Recurrence After Breast-Conserving Therapy or Mastectomy for Stage I and II Breast Cancer: Pooled Results of Two Large European Randomized Trials. JCO
19: 1688-1697
[Abstract][Full Text]
Pierce, L. J., Strawderman, M., Narod, S. A., Oliviotto, I., Eisen, A., Dawson, L., Gaffney, D., Solin, L. J., Nixon, A., Garber, J., Berg, C., Isaacs, C., Heimann, R., Olopade, O. I., Haffty, B., Weber, B. L.
(2000). Effect of Radiotherapy After Breast-Conserving Treatment in Women With Breast Cancer and Germline BRCA1/2 Mutations. JCO
18: 3360-3369
[Abstract][Full Text]
Lohrisch, C., Jackson, J., Jones, A., Mates, D., Olivotto, I. A.
(2000). Relationship Between Tumor Location and Relapse in 6,781 Women With Early Invasive Breast Cancer. JCO
18: 2828-2835
[Abstract][Full Text]
van Dongen, J. A., Voogd, A. C., Fentiman, I. S., Legrand, C., Sylvester, R. J., Tong, D., van der Schueren, E., Helle, P. A., van Zijl, K., Bartelink, H.
(2000). Long-Term Results of a Randomized Trial Comparing Breast-Conserving Therapy With Mastectomy: European Organization for Research and Treatment of Cancer 10801 Trial. JNCI J Natl Cancer Inst
92: 1143-1150
[Abstract][Full Text]
Obedian, E., Fischer, D. B., Haffty, B. G.
(2000). Second Malignancies After Treatment of Early-Stage Breast Cancer: Lumpectomy and Radiation Therapy Versus Mastectomy. JCO
18: 2406-2412
[Abstract][Full Text]
Giess, C. S., Keating, D. M., Osborne, M. P., Rosenblatt, R.
(1999). Local Tumor Recurrence following Breast-Conservation Therapy: Correlation of Histopathologic Findings with Detection Method and Mammographic Findings. Radiology
212: 829-835
[Abstract][Full Text]
Meijer-van Gelder, M. E., Look, M. P., Vries, J. B.-d., Peters, H. A., Klijn, J. G.M., Foekens, J. A.
(1999). Breast-Conserving Therapy: Proteases as Risk Factors in Relation to Survival After Local Relapse. JCO
17: 1449-1449
[Abstract][Full Text]
Riley, G. F., Potosky, A. L., Klabunde, C. N., Warren, J. L., Ballard-Barbash, R.
(1999). Stage at Diagnosis and Treatment Patterns Among Older Women With Breast Cancer: An HMO and Fee-for-Service Comparison. JAMA
281: 720-726
[Abstract][Full Text]
El-Tamer, M., Homel, P., Braverman, A. S., Wolberg, W. H., Robins, H. I., Goldhirsch, A., Coates, A. S., Colleoni, M., Gelber, R. D., Raffle, A.E., Evans, R. A., Overgaard, M., Rose, C., Mouridsen, H., Ragaz, J., Jackson, S. M., Spinelli, J. J., Hellman, S.
(1998). Radiotherapy and Chemotherapy in High-Risk Breast Cancer. NEJM
338: 329-333
[Full Text]
De Ruysscher, D, Specenier, P, Spaas, P
(1996). Minerva's comment was not evidence based. BMJ
313: 113-113
[Full Text]
Del Mastro, L., Costantini, M., Bianco, A. R., Newman, M. D., Evans, R. A., Bonadonna, G., Valagussa, P., Henderson, I. C.
(1995). Adjuvant Chemotherapy in Breast Cancer. NEJM
333: 596-597
[Full Text]
Previous
