CONTROVERSIES IN BREAST-CONSERVING TREATM ENT OF EARLY BREAST-CANCER

Background: As the incidence of breast cancer continues to increase, o ncologists are challenged to make every effort to optimize its primary treatment, to define standards and to scrutinize the results of clini cal studies. Purpose: From the radiooncological point of view some con troversially discussed issues are addressed: 1) extent of primary surg ery, 2) prognostic significance of extensive intraductal component (EI C), 3) impact of radiation therapy on local control and long-term surv ival, 4) time of first recurrence and its effect on long-term survival , 5) breast-conserving treatment without breast irradiation, and 6) th e efficacy of the systemic hormone or chemotherapy in preventing local relapse. Results: 1) On the basis of available data from prospective randomized studies, the superiority of quadrantectomy to tumorectomy w ith negative margins has not been proven. 2) The prognostic significan ce of EIC for 'in-breast relapses' is abrogated if tumorectomy specime ns have histologically clear margins and the breast is irradiated in a risk-adapted manner following tumorectomy. 3) Postoperative irradiati on reduces the rate of local recurrences and improves the overall surv ival in irradiated patients. 4) There is a strong correlation between early locoregional relapse and the occurrence of distant metastases an d, consequently, a worse prognosis. As the critical time interval is i n the range of 4 years, a significant difference in the 5-year surviva l rates cannot be expected between irradiated and nonirradiated patien ts. 5) Postoperative irradiation after tumorectomy or quadrantectomy i s an indispensable component within the concept of breast conservation . 6) Adjuvant hormone therapy or chemotherapy cannot replace homogenou s breast irradiation following tumorectomy or quadrantectomy. Conclusi on: Abandonment of postoperative irradiation in patients suffering fro m apparently favorable breast cancer should be restricted to controlle d and prospectively randomized studies with well-defined endpoints.