The continuing importance of adequate surgery for operable breast cancer: significant salvage of node-positive patients without adjuvant chemotherapy.

Abstract

Five hundred and forty-four patients with primary operable breast cancer were treated by the senior author (JAU) from 1965 to 1970, following a plan of selective surgery involving radical mastectomy (RM), extended radical mastectomy (ERM), and modified radical mastectomy (MRM) applied to appropriate patients. Postoperative radiation therapy was administered to the peripheral regional nodes in 90 percent of node-positive patients. No patient received adjuvant chemotherapy. Significant findings include: • excellent 10-year no-evidence-of-disease (NED) survival following MRM in patients with noninfiltrating cancers (97 percent) and minimal infiltrating cancers (86 percent) • comparable survival (70 percent versus 67 percent alive at 10 years, 63 percent versus 60 percent NED at 10 years) following RM or ERM, in patients with more advanced stages of breast cancer • 10-year survival of 59 percent (50 percent NED) for all patients with axillary node metastases • net local recurrence rate of six percent at 10 years in the 496 patients with infiltrating cancers (44 percent of whom had positive axillary nodes) • internal mammary (IM) node metastases present in 26 percent of ERM patients, with 10-year NED survival of 70 percent when all nodes were negative, 45 percent if only IM nodes were positive, and 35 percent when both axillary and IM nodes were positive. Significant salvage of patients with positive axillary nodes (50 percent NED at 10 years) has been attained through complete excision of the breast and meticulous dissection of the regional nodal depots. Since none of these patients received adjuvant chemotherapy, it is evident that most patients with negative nodes and many with positive nodes do not have systemic disease at the time of primary therapy. Since current methods of adjuvant chemotherapy have improved the five-year survival rates of patients with positive axillary nodes by only 10 percent to 15 percent over that obtained by similar primary therapy in control groups. the current tendency to minimize the importance of adequate primary therapy is irrational and to be condemned. Patients will benefit most when adequate primary therapy with excellent local control is combined with aggressive multidrug adjuvant chemotherapy in appropriate cases.