Mark Trombetta, MD, FACR
Jean-Michel Hannoun-Levi, MD, PhD, MSD
Worldwide, nearly 1.7 million women will be diagnosed with breast cancer. Of that number, nearly 300,000 Americans and more than 500,000 Europeans will be diagnosed with both invasive and in situ breast cancers.1,2 Breast-preserving surgery will initially be performed on approximately 60% of these patients. Of that number, approximately 2% to 20% (depending on multiple factors) will develop an isolated, second in-breast tumor event over the course of their lives, representing a large number of women.
Historically, salvage mastectomy has been the accepted standard of care in this circumstance. However, most clinicians would be surprised to know there are no phase III data to support salvage mastectomy as a sole option. Surveys of patients who have undergone mastectomy when other choices were available revealed that up to 40% of respondents have postmastectomy regret, which has led to a depressed self-image and clinical depression in a substantial number of patients.3-5 Cosmesis is dramatically affected, and functional changes, such as scoliosis, can result based on asymmetry of body mass.
Although reconstruction is possible in many patients, the reconstructed breast rarely looks the same and never substitutes adequately for the natural breast, in the opinion of many patients. We also know reconstruction in the post-irradiation setting can lead to increased fibrosis of the entire chest wall and healing difficulties.
Recently, disfiguring and unnecessary mastectomies have been on the rise due to multiple factors, such as social media influences and high-profile celebrity opinions. This is a disturbing trend that threatens to reverse 30-plus years of evidence-based breast conservation. It is our duty as clinicians to educate our patients and our surgical, radiation, and medical oncology colleagues to prevent therapeutics based on hysteria or media influences.
Update on Approaches to Breast Preservation
Within the past decade, multiple publications have shown the equivalence of overall and disease-free survival in patients who have had an isolated, second in-breast tumor event and undergone repeat lumpectomy and focal retreatment radiotherapy.6-10 In these studies (some done early on), the feasibility of repeat breast-conservation therapy was demonstrated; however, early results showed variable cosmetic outcomes. The more recent studies have shown good-to-excellent results in up to 90% of patients.8-10
Of these studies, the largest to date was the GEC-ESTRO study of 217 patients.10 However, the longest follow-up study to date is a Nice study of 159 patients treated with brachytherapy.11 At a median follow-up of 71 months, this study showed a relapse-free survival of 97.4% and an overall survival of 91.2%—once again with good-to-excellent cosmesis in the vast majority of patients.
A recent RTOG study of twice-daily focused retreatment radiotherapy after repeat lumpectomy has shown 5-year results mimicking the previously noted favorable results, with a 5% local failure rate (61 of 64 retained breasts) and good-to-excellent cosmesis in 93% of patients.12 Additionally, 90% of patients evaluated were candidates for retreatment.
In all of these studies, patient satisfaction has been exceptional. One constant has been noted in patients who have had an isolated, second in-breast tumor event and were presented with a choice of repeat breast conservation vs mastectomy. Even in patients who had higher (fair or poor) Harvard cosmesis scores after repeat breast conservation, virtually all strongly preferred their own breast to mastectomy.
In summary, we believe patients who have isolated ipsilateral small breast tumor recurrences and whose breast size can accommodate repeat lumpectomy and focused breast repeat radiotherapy (which is the great majority of carefully followed patients) should be first considered for repeat breast-conservation therapy. The evidence to date clearly supports such an approach. Mastectomy is a viable alternative, but we suggest changing the paradigm to give first consideration to repeat breast preservation. Every eligible patient should be presented with a repeat breast-preservation option.
DISCLOSURE: Drs. Trombetta reported no conflicts of interest. Dr. Hannoun-Levi has served in a consulting or advisory role for Eckert & Ziegler BEBIG.
1. American Cancer Society: Cancer Facts & Figures 2020. Available at https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf. Accessed June 1, 2020.
2. Ferlay J, Colombet M, Soerjomataram I, et al: Cancer incidence and mortality patterns in Europe: Estimates for 40 countries and 25 major cancers in 2018. Eur J Cancer 103:356-387, 2018.
3. Ganz P, Schag AC, Lee JJ, et al: Breast conservation versus mastectomy: Is there a difference in psychological adjustment or quality of life in the year after surgery? Cancer 69:1729-1738, 1992.
4. Rowland JH, Desmond KA, Meyerowitz BE, et al: Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 92:1422-1429, 2000.
5. Maunsell E, Brisson J, Deschenes L: Psychological distress after initial treatment for breast cancer: A comparison of partial and total mastectomy. J Clin Epidemiol 42:765-771, 1989.
6. Montagne L, Hannoun A, Hannoun-Levi JM: Second conservative treatment for second ipsilateral breast tumor event: A systematic review of the different re-irradiation techniques. Breast 49:274-280, 2020.
7. Trombetta M, Julian TB, Werts ED, et al: Long term cosmesis following lumpectomy and brachytherapy in the management of carcinoma of the previously irradiated breast. Am J Clin Oncol 32:314-318, 2009.
8. Trombetta M, Julian TB, Hannoun-Levi JM: Brachytherapy in the management of ipsilateral breast tumor recurrence, in Montemaggi P, Trombetta M, Brady L (eds): Brachytherapy: Principles and Practice: An International Perspective. Heidelberg, Germany; Springer-Verlag; 2016.
9. Harms W, Budach W, Dunst J, et al: DEGRO practical guidelines for radiotherapy of breast cancer VI: Therapy of locoregional breast cancer recurrences. Strahlenther Onkol 192:199-208, 2016.
10. Hannoun-Levi JM, Resch A, Gal J, et al: Accelerated partial breast irradiation with interstitial brachytherapy as second conservative treatment for ipsilateral breast tumour recurrence: Multicentric study of the GEC-ESTRO Breast Cancer Working Group. Radiother Oncol 108:226-231, 2013.
11. Montagne L, Gal J, Chand ME, et al: GEC-ESTRO APBI classification as a decision-making tool for the management of 2nd ipsilateral breast tumor event. Breast Cancer Res Treat 176:149-157, 2019.
12. Arthur DW, Winter KA, Kuerer HM, et al: Effectiveness of breast-conserving surgery and 3-dimensional conformal partial breast reirradiation for recurrence of breast cancer in the ipsilateral breast: The NRG Oncology/RTOG 1014 phase 2 clinical trial. JAMA Oncol 6:75-82, 2019.
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.
Dr. Trombetta works at Allegheny Health Network, Drexel University College of Medicine, Pittsburgh. Dr. Hannoun-Levi is employed by Antoine Lacassagne Cancer Center, University of Cote d’ Azur, Nice, France.