Patey’s Mastectomy. Patey’s (Radical) Mastectomy Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales)...
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Transcript of Patey’s Mastectomy. Patey’s (Radical) Mastectomy Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales)...
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Patey’s Mastectomy
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Patey’s (Radical) Mastectomy
Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales) MMSc (Newcastle)
Professor of SurgeryDepartment of SurgeryKing George’s Medical UniversityLucknow, Uttar Pradesh, India
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Patey’s Mastectomy
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Breast Cancer
A relaxed approach to local treatment in the
last 20 years
Loco Regional Recurrence (LRR) represents a
biologic disease rather than a treatment failure
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NEW – Not so New
Recognition of the importance of extent and
quality of primary surgery in determining
outcomes
‘R’ = Residual
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Local treatment
Improved loco regional control
Improved survival
Improved local treatment – not been a subject of intensive, high profile randomised clinical trials
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Adjuvant radiotherapyOvergaard et al, NEJM 1997; 337:949Ragaz et al, NEJM 1997; 337:956Hellman S, NEJM 1997; 337:996
Radical surgical treatment
Quality of life
Local treatment+
Systemic treatment
Survival
Survival
Survival
Breast cancer : the survival
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Conservation Technique
Seek LRR
Require intensive radiotherapy
Chemotherapy
Long term follow-up monitoring
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Psychological Benefits of
Conservation Radiotherapy Outcome
Chemotherapy
Is this really good or
as hoped
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An Alternative is
More radical surgery to maximize local control ± Immediate breast reconstruction as cherished
Good loco-regional control related to improved
survival rates
Avoid adjuvant therapies
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The Benefits
Breast conservation treatment unsuitable for
50% patients Oldhoff 1992
Surgery remains necessary to treat large tumors
Surgery for unresponsive to chemotherapy
Long term adverse effects of high dose radiotherapy Breast Can Res Treat 1998; 47:101
Lower treatment and monitoring cost
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Breast Conservation – a Commodity
Early stage disease – a reference bias
Epidemiologically downstage – screen achieved
Large breasts – well nourished population
Radiotherapy support – overburdened
Meticulous surgical technique – sentinel node training
Chemotherapy mandate – ensured compliance, subsidy
Intensive follow up – education / means
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LRR / Survival Conservatively treated
n=241 Radically treated
n=210
LRR 97 (40.2%) 29 (13.8%)*
Total alive 102 123
Percentage Alive
42.3 % 58.5 %**
Median survival time (mo)
100 >132
*p < .001, ** p < .01
Annals Surg Oncol 1999; 6 (5) : 455 - 60
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Survival Related to Tumor SizeTumor size
Conservatively treated Radically treated
No Alive Percent Median survival (mo)
No Alive Percent Median survival (mo)
P value
T1 49 / 81 60.4 % >132 55 / 73 75.3 % >132 <.05
T2 43 / 119 36.1 % 89 49 / 97 50.5 % 115 NS
T3 9 / 30 30.0 % 49 10 / 21 47.6 % 73 NS
T4 1 / 9 11.1 % 39 09 / 19 47.3 % 83 <.05
NS = Not Significant Annals Surg Oncol 1999; 6 (5) : 455 - 60
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Who developed systemic recurrence ? The survival disadvantage in conservatively treated group
=
Excess of patients in the group with LRR who subsequently developed SR
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An outcome at variance
Clear survival advantage for those who achieved good loco-regional control
A hypothesis which has not been a subject of high profile prospective RCT
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Overtaken by “new biology”
“Breast cancer is systemic from its onset and lymphnode involvement has significance only as an indicator of systemic spread”
Fisher
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Halstedian paradigm Radicality of treatment - panacea for cure
Paradigm shift Breast cancer - a systemic disease Fisher’s rhetoric
New millenium paradigm Loco-regional recurrence - harbinger of systemic recurrence
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Equivalence of Radical vs Conservative
Equivalent LRR between conservative and radical because of
multicentric trials - ? quality control in surgery
Euphemism in Group allocation (Milan - Veronesi) : Quadrantectomy, meticulous axillary dissection and high
dose post-op radiotherapy = radical mastectomy
Powerful, high profile, randomised, multicentric and
controlled clinical trials neglect assessment of surgical
technique
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In SummaryRadical local treatment contributes significantly to survival
Reduced loco-regional recurrence influences survival
High quality loco-regional control should be emphasized as is systemic therapy
Assessment of surgical techniques should be includedin studies in which surgery is a component of therapy
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David Patey