Changes in management techniques and patterns of disease recurrence over time in patients with breast carcinoma treated with breast‐conserving therapy at a single institution

Abstract

BACKGROUND The authors reviewed changes in the initial clinical presentation, management techniques, and patterns of disease recurrence over time (1981–1996) in patients with breast carcinoma treated with breast‐conserving therapy (BCT) at a single institution. The goals of the current study were to determine the frequency and use of optimal local and systemic therapy techniques and to evaluate the impact of these changes on treatment efficacy. METHODS Six hundred seven patients with American Joint Committee on Cancer Stage I or II invasive breast carcinomas treated with BCT at William Beaumont Hospital (Royal Oak, MI) constituted the study population. All patients received at least an excisional biopsy of the primary tumor, an axillary lymph node staging procedure, and postoperative radiotherapy (RT) (a median tumor bed dose of 61 Gray [Gy] was administered). All sides were reviewed by one pathologist. Numerous clinicopathologic and treatment‐related factors were analyzed to monitor changes that occurred over time. Changes in patterns of disease recurrence and treatment efficacy over time also were analyzed. RESULTS Over the time period analyzed, changes at initial presentation included an increase in the mean age at diagnosis (age 56.1 years vs. 61.4 years; P < 0.001), a decrease in the number of patients with clinically palpable tumors (78% vs. 36%; P < 0.001), a decrease in the mean tumor size (2.2 cm vs. 1.6 cm; P < 0.001), but no change in the percentage of patients with negative lymph nodes (79% vs. 78%; P = 0.83). No differences over time were observed in mean tumor grade (2.0 vs. 1.9; P = 0.2) or the presence of angiolymphatic invasion (27% vs. 26%; P = 0.25). Changes in surgical management and pathologic assessment included the more frequent use of reexcision (46% vs. 81%; P < 0.001), larger mean total volumes of breast tissue specimens excised (115 cm3 vs. 189 cm3; P = 0.001), a larger percentage of patients with final negative surgical margins (74% vs. 97%; P < 0.001), and a small increase in the mean number of lymph nodes excised (13.8 lymph nodes vs. 14.1 lymph nodes; P = 0.01). The only other significant change in the pathologic management of patients over time included a doubling in the mean number of slides examined (10.6 slides vs. 21.1 slides; P < 0.001). Changes in adjuvant local and systemic therapy included an increase in the percentage of patients treated with > 60 Gy to the tumor bed (66% vs. 95%; P < 0.001), a doubling in the mean number of days from the last surgery to the start of RT (24 days vs. 50 days; P < 0.001), and a decrease in the use of regional lymph node RT (24% vs. 8%; P < 0.001). The use of adjuvant tamoxifen increased from 10% to 61% (P < 0.001). Finally, improvements were observed in the 5‐year and 12‐year actuarial rates of local disease recurrence (8% vs. 1% and 21% vs. 9%, respectively; P = 0.001) and distant metastases (12% vs. 4% and 22% vs. 9%, respectively; P = 0.006). No changes in the mean number of years to ipsilateral (6.5 years vs. 6.4 years; P = 0.59...

Improving local control with breast‐conserving therapy

“…Finally, the delivery of a radiation boost to the tumor bed after whole-breast radiation declined during the study period. Our results mostly parallel those recently reported by Pass et al 32 and suggest that changes in the management of breast carcinoma may lead to further declines in IBTR rates after BCT.…”

Cutaneous soft tissue sarcoma incidence patterns in the U.S.

“…Recently, breast-sparing surgery with adjuvant radiation therapy largely has replaced mastectomy with lymph node dissection for women with stage I and II breast carcinoma. [43][44][45][46] Consequently, the number of radiation treatments has increased, and cutaneous complications of radiation therapy have risen in frequency. 42,[47][48][49] Second, epithelioid hemangioendotheliomas, which previously were considered of intermediate or borderline malignancy, are regarded now as a variant of AS.…”

Presence of Lobular Carcinoma In Situ Does Not Increase Local Recurrence in Patients Treated with Breast-Conserving Therapy

“…In addition, with the exception of the report of Ben-David et al 8 , which was a matched pair analysis, other studies that have examined this question have not taken into account the increased frequency of the diagnosis of LCIS in more recent time periods. This is important since rates of local recurrence have decreased steadily over time 19,20 , and differences in the dates of treatment of patients with and without LCIS have the potential to mask the effect of the lesion on local control. Local recurrence rates have decreased over time due to improved techniques in both surgery and RT, more detailed pathologic evaluation of margin status, and increased use of adjuvant therapies such as tamoxifen.…”