Patey’s Mastectomy

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

Patey’s Mastectomy

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

NEW – Not so New

Recognition of the importance of extent and

quality of primary surgery in determining

outcomes

‘R’ = Residual

Local treatment

Improved loco regional control

Improved survival

Improved local treatment – not been a subject of intensive, high profile randomised clinical trials

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

Conservation Technique

Seek LRR

Require intensive radiotherapy

Chemotherapy

Long term follow-up monitoring

Psychological Benefits of

Conservation Radiotherapy Outcome

Chemotherapy

Is this really good or

as hoped

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

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

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

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

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

Who developed systemic recurrence ? The survival disadvantage in conservatively treated group

=

Excess of patients in the group with LRR who subsequently developed SR

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

Overtaken by “new biology”

“Breast cancer is systemic from its onset and lymphnode involvement has significance only as an indicator of systemic spread”

Fisher

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

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

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

David Patey