Why are local recurrences after breast-conserving therapy more frequent in younger patients?

The influence of patient age on risk of recurrence in the breast was retrospectively studied in 496 stage I-II invasive ductal carcinomas treated by macroscopically complete primary tumor excision followed by radiotherapy. With a median follow-up of 71 months, local recurrence occurred in 13 of 62 (21%) patients younger than 40 years, compared with 48 of 434 (11%) older patients (P less than .025). Cox multivariate analysis of 18 parameters identified four that significantly determined risk: major lymphocytic stromal reaction (MCR), unsatisfactory resection margins, increasing histologic grade, and extensive intraductal cancer (DCIS) within the primary tumor. Compared with older patients, those younger than 40 years had tumors that more often exhibited MCR (36% v 20%, P less than .01), histologic grade 3 (42% v 28%, P less than .025), and very extensive DCIS (21% v 6%, P less than .001). The status of resection margins did not differ significantly between younger and older patients. Restriction of Cox analysis to patients younger than 40 indicated that risk was adequately described by MCR and percentage of DCIS, without consideration of grade or margins. For patients younger than 40, local failure occurred in four of five (80%) tumors with both MCR and more than 50% DCIS, in eight of 25 (32%) with either, and one of 32 (3.1%) with neither of these morphologic features. This study suggests that the higher local failure risk observed in patients younger than 40 years reflects the greater prevalence of certain morphologic characteristics in breast cancers in younger patients. Age itself does not appear to be an independent determinate of risk.

Time course and prognosis of local recurrence following primary radiation therapy for early breast cancer.

The frequency, time course, and prognosis of local recurrence following primary radiation therapy in 152 patients with early breast cancer treated before 1967 were examined. Local recurrence occurred at a constant rate over the first 14 years after treatment. The crude 15-year local recurrence rate was 22%. Of the 30 patients who developed an isolated local recurrence and underwent definitive secondary surgery, the 10-year freedom from distant relapse rate was 50%. These results indicate that breast cancer patients treated by primary radiation therapy require long-term follow-up to detect curable local recurrences.

Is breast conservation after local recurrence feasible?

The feasibility of conservative salvage surgery was addressed in a clinicopathologic study of the results of wide excision for 50 selected parenchymal intramammary recurrences after standard breast conserving treatment. After median follow-up of 51 months, 16 (32%) second local failures were observed (5-year local control 62%). Cox multivariate analysis of 18 parameters indicated that only disease-free interval and resection margins significantly influenced local control. 5-year local control was 92% for recurrences occurring after 5 years vs. 49% for shorter intervals, and 73% for negative vs. 36% for positive or indeterminate margins. Local control appeared independent of morphologic features, initial tumour stage, patient age, recurrent tumour size and location. Median survival after second local failure was 33 months; tertiary therapy obtained ultimate local-regional control in 8 of 16 cases. The authors conclude that wide excision is a particularly satisfactory alternative to salvage mastectomy for late recurrences. Negative margins are essential. Further study will be required to establish additional guidelines allowing improved patient selection.

Pain infirmity and psychotropic drugs in oncology.

The treatment of cancer pain by psychotropic drugs is a method which has been employed for a long time [8] and in which the results obtained have appeared very interesting from the beginning: there is a high percentage of success, rapid action, absence of addiction, and although there are sometimes unpleasant side-effects, they are reversible when the treatment is stopped. Even after several years of application, this therapy still sets some unsolved problems. Some consider that psychotropics are not real analgesics, but that they work on the emotional reaction rather than on the pain itself [3]. Still others consider that the results are obtained only at the price of a state of prostration of the patient similar to that obtained after lobectomy. Finally, this procedure is reproached as having unpredictable results and indications difficult to define. We think that what has, up to now, prevented these types of problems from being solved has been the absence of a really objective evaluation of the pain in the patients observed. We have wrestled with this problem for several years [1,2], and offer the following hypothesis: what is important in considering chronic pain is, above all, the infirmity conferred upon the patient. If "pain" in the broad sense of the term lends itself to objective evaluation with difficulty, it is not the same with respect to infirmity. A method of evaluation of the physical disability intended for routine practice in a cancer center has been used on a series of 100 patients. The results obtained in this series have been analyzed and give the answer to questions such as mechanism of action, indications of psychotropic drugs and prognosis of cancer pain.

Late breast recurrence after lumpectomy and irradiation.

For 276 patients with early breast cancer followed from 10-21 years after lumpectomy and radiotherapy, the recurrence rate in the treated breast was 15.6%, and 7.2% developed contralateral breast cancer. Only 63% of breast recurrences occurred within 5 years, and the remainder were "late failures," with 5 of the 43 recurrences observed after 10 years. The proportion of failures occurring late was greater for T1 than for T2 tumors (53% vs 25%). Twenty-six percent of early recurrences were inoperable, and an adverse impact of early recurrence on 10-year survival was clearly demonstrable. Late recurrences were all operable and did not appear to be associated with decreased survival. Only 16 of the 36 patients (44%) with operable breast recurrence ever developed metastatic disease, and 5 year survival following salvage therapy was 62%. Although the treated breast remains at continuous cancer risk even beyond 5 year, the prognosis of late recurrence appears quite similar to that of contralateral breast cancer. We do not consider the phenomenon of late recurrence to lend support to a policy of primary mastectomy, just as the existence of contralateral breast cancer does not justify routine "prophylactic" contralateral mastectomy.

Contralateral breast cancer and other second malignancies in patients treated by breast-conserving therapy with radiation.

Metachronous contralateral breast cancers and other second malignancies were evaluated in 2,850 patients treated between 1960 and 1981 primarily with radiotherapy (RT) either alone or following breast-conserving surgery. One hundred eighty-four contralateral cancers were observed in 22,491 patient-years of observation (818 per 10(5) patient-years), with a cumulative probability of 4.5% at 5, 7.9% at 10, and 11% at 15 and 20 years. Compared to patients with unilateral tumors, those destined to develop contralateral cancers were younger (mean age 51.9 vs 56.6) and more often gave a family history of breast cancer. Contralateral breast cancers were more frequent for more extensive tumors (T3 10% vs T1-26%; with inflammatory signs 10.6% without 6%), and in patients with ipsilateral local recurrence (with 9.1%, without 5.6%). Patients with contralateral cancers had a significantly less favorable survival experience (15-year actuarial survival after primary therapy 42%) than patients without contralateral cancer (15-year survival 65.5%). In early stage patients treated with conservative surgery and RT, contralateral cancer was not prognostically more favorable than ipsilateral breast recurrence. Among 72 other second malignancies (320 per 10(5) patient-years) were 2 soft tissue sarcomas in the irradiated area. This corresponds to an incidence of 21 cases per 10(5) patient-years for survivors beyond the fifth year. The possible influence of RT on contralateral cancers and other second malignancies is discussed.

Mammary recurrences in women younger than forty.

The crude mammary recurrence rate was studied in 5-year age intervals for 1,382 Stage I and II breast cancer patients treated by conservative surgery and radiation therapy and followed for a median of 11 years. Patients younger than 40 had a significantly higher local recurrence rate (41/210, 19%) than did older patients (106/1172, 9%). The majority of excess recurrences in the younger patients occurred early, with recurrence rates between 5 and 10 years being equal for the 2 age groups. A comparison of the clinical characteristics of the patient groups yielded no obvious explanation for the higher local recurrence rate in the younger patients, and 15-year cancer-specific survival was identical. Within the younger age group, recurrence rate was independent of clinical tumor size, and was unaffected by adjuvant treatment. Young patients with positive axillary nodes or negative hormone receptors appear to be at particularly high risk for mammary failure. Despite this apparent correlation with biologic aggressiveness, the 41 patients with mammary recurrence experienced long-term survival from time of primary treatment which was not significantly worse than that of patients not having had local recurrence. For 37 patients with operable mammary recurrence, the 10-year survival from time of salvage surgery was 64%.

The second ten years: long-term risks of breast conservation in early breast cancer.

A retrospective cooperative study was undertaken to analyze the fate of 300 clinical Stage I and II breast cancer patients who were alive and apparently cured with both breasts preserved, 10 years following primary limited surgery with irradiation. All patients had been treated by tumor excision, with or without axillary dissection, followed by megavoltage radiation therapy. Follow-up ranged from 10.5 to 26 years, median 14.5 years. The overall actuarial survival (Kaplan-Meier) of the 300 "cured" patients was 86% at 15 years and 78% at 20 years, with 38.5% of deaths attributable to breast cancer. The actuarial probability of remaining free of metastatic disease was 91% at both 15 and 20 years, independent of age or clinical stage. Sixteen patients (5.3%) developed recurrent cancer in the treated breast beyond the tenth year, the actuarial probability of remaining free of breast recurrence being 94% and 90% at 15 and 20 years, respectively. Contralateral breast cancers developed during the second decade in 5 patients, with a cumulative risk of 6.5% at 20 years. Significant treatment-related problems appeared during the second decade in 5 patients, including one chest wall sarcoma; all of these patients had received at least 60 Gy to breast and regional nodal areas. A comparison of these results with those in the literature allowed the following conclusions to be drawn: (a) the risk of death, as well as breast cancer mortality during the second decade, are similar for both conservatively and radically treated patients with Stage I and II breast cancer; (b) the risk of contralateral breast cancer is not greater than that observed following primary radical surgery without radiation therapy; (c) ipsilateral breast "recurrences" continue to occur at about 1% per year during the second decade. Such late recurrences are highly operable and have a favorable prognosis; (d) late progression of treatment-related sequelae is uncommon. This analysis supports the continued use of breast-conserving surgery with radiation therapy in the treatment of Stage I and II breast cancer.

The prognostic significance of late local recurrence after breast-conserving therapy.

Of 178 local recurrences occurring in 1593 patients with clinical Stages I-II breast cancer treated by conservative surgery and megavoltage radiotherapy, 71 were diagnosed after the 5th year. Compared with recurrences occurring prior to 60 months, late recurrences were less frequently inoperable (1/71, 1.4%, versus 18/107, 17%, p less than 0.001), were more often located at a distance from the initial primary tumor (23/71, 32%, versus 15/106, 14%, p less than 0.005), and had a more favorable prognosis (5-year survival 84% versus 61% for late and early operable recurrences, respectively, p = 0.05). Five-year metastasis-free survival after late failure depended mainly on the anatomic extent of the recurrence (87% for recurrences apparently confined to the breast versus 34% for relapses involving the axilla, p less than 0.002). Prognosis of late recurrence appeared to be unaffected both by location of the recurrence within the breast and by the type of salvage operation used (mastectomy versus wide excision). Local-regional control after salvage surgery was satisfactory (89% at 5 years). Whereas recurrence in the breast prior to 5 years profoundly affected survival after initial diagnosis, patients with late failure had identical 15-year survival as other 5-year survivors who never failed locally. Late recurrences were more frequent in patients younger than 40 at initial treatment, and in patients who had inadequate radiotherapy. We conclude that late local recurrences after breast conservation do not represent a serious management problem.

How important is adequate radiotherapy for the long-term results of breast-conserving treatment?

The influence of radiotherapy dose parameters on longterm local control was studied in 134 clinical stage I-II breast cancer patients treated by tumorectomy and telecesium therapy during the 1960s. Recurrence in the breast was more frequent in patients receiving 75 Gy or less to the tumor bed (31% versus 15% for higher doses, p less than 0.05), and weekly dose rates of less than 8 Gy/week were associated with increased local-regional failure (30% versus 15% for higher weekly doses, p less than 0.01). The majority of local-regional failures were observed in the 53 patients having "inadequate" total or weekly radiotherapy doses (18/53, 34% versus 9/81, 11%, p less than 0.001). The importance of adequate radiotherapy applied to both older patients, as well as those younger than 40, who appear inherently to have a higher risk of local relapse. The mean interval to recurrence was markedly longer for inadequate radiotherapy (111 months, versus 75 months for adequate treatment), so that significant differences in local control became apparent only after 5 years. These results underscore the importance of radiotherapy technique in breast-conserving treatment, and suggest that an excessive reduction in the intensity of radiotherapy may result in an inordinate number of late local failures.

[Immune competence before and after curative radiotherapy in breast cancer (author's transl)]. / Bilan immunitaire avant et après radiothérapie curative de malades porteuses de cancer du sein.

The level of non-specific immune response was evaluated in 409 operable breast cancer patients by a battery of classical tests performed at least before and after treatment. We propose a synthetic classification of the various tests into 5 categories (from I 1 to I 5) of growing pejorative weight for a rapid and better understanding between the laboratory and the clinicians and also for overall comparison in time. With this type of evaluation the percentage of patients exhibiting depressed immune response was 14 per cent initially and rose to 39 per cent at the end of irradiation. Six months later, however, only 3 per cent of the patients had an immune assessment lower than the initial level. The pronounced immune depression observed by other authors concerned mainly patients having undergone post-operative irradiation after removal of the breast. The curative treatments used here in the hope of avoiding radical breast surgery was performed under much different ballistic, biological and psychological conditions which should be taken into account before condemning the dangers of this method.

[Reevaluation of indications for adjuvant hormone therapy in primary breast cancer with high metastatic risk]. / Réévaluation des indications d'une endocrino-hormonothérapie adjuvante dans les cancers primitifs du sein à haut risque métastatique.

This study concerns the correlation between ER and PR status, menopausal status and the effect of adjuvant hormonotherapy in high risk primary breast cancer patients. We have compared the results obtained in a randomized trial (Institut Paoli-Calmettes, Marseille) with those of a historic series (Centre René Huguenin, Saint-Cloud). The patients presented the same clinical and histological criteria and received identical therapeutic protocols (chemotherapy and/or hormonotherapy). Compared with patients receiving no adjuvant treatment, it appeared that: 1) in post-menopausal patients, a significant detrimental effect of tamoxifen was found in ER-negative patients, while in ER-positive patients hormonal treatment was well correlated with both the presence and level of steroid receptors; 2) in pre-menopausal patients, hormonal therapy (oophorectomy + tamoxifen) appeared to be mediated by a complex mechanism involving more than an ER-positive cell population. In the light of the published results, the present findings underline the importance of reevaluating the indications of hormonotherapy in terms of hormone receptors and menopausal status. They also indicate the importance of biological factors in the evaluation of response to therapy. They can identify, subsets of patients in whom a given therapeutic protocol is detrimental, even though it may be beneficial for the overall population. heterogeneity in response to therapy among patient subsets is one of the most important problems which confronts medical statisticians and clinical investigators.

[Clinically impalpable mammary carcinoma: morphologic and histogenetic analysis. Apropos of 114 cases]. / Carcinomes mammaires impalpables: analyse morphologique et histogenèse. A propos de 114 cas.

In a population of 2,372 consecutive cases of breast carcinomas, 114 cases of clinically occult non palpable breast lesions have been diagnosed (4.8%). 51% of them can be considered as minimal breast carcinomas (MBC) by Gallager's definition and 72% by that of the American College of Surgeons; whatever the definition this category has an excellent prognosis with 11% of axillary invasion for the infiltrating tumors under 5 mm and 7% for these under 10 mm and 100% 5-year survival rate in both cases. The category of infiltrating tumors of over 5 mm and 10 mm also has a good prognosis with 21% and 26% of axillary lymph node invasion respectively, with a survival rate of 83.82% and 77.92%. The comparative histological analysis shows at this stage an increase in the intraductal carcinomas (IC) (35% instead of 6% for the palpable carcinomas), the infiltrating ductal carcinomas with predominant intraductal component (IDCPIC) (19% instead of 12%) and the tubular carcinomas (11% instead of 3%). The study of the peritumoral and environmental mastopathy and the histological repartition, confirms the classical histogenetic arguments regarding breast carcinomas.

[Curative radiotherapy with hope of saving the breast in operable breast cancers 403 cases with 5-year survival]. / Radiothérapie curative à espérance conservatrice des cancers du sein opérables. 403 cas de 5 ans

Between 1960 and 1975, 1 078 operable mammary carcinomas were treated by caesium therapy with the objective of conserving the breast. The authors analyse the indications for and results of this treatment in the 403 cases which have had more than 5 years follow up (241 cases were irradiated as primary treatment, 162 after having a simple tumorectomy). For the whole group 92 mastectomies were ultimately carried out: in 30 of them no tumour was found in the operative specimen. The tumorectomy cases, restricted to stage 1 of the UICC classification (pre 1962) -- PRV 0 IGR yielded the best results: 86 per cent 5 yeat cures with 9 out of 10 women retaining both breasts. The primary irradiation cases, all types considered, gave results comparable with those for primary radical surgery: 58 per cent 5 year cures-but 2 out of 3 women retained both breasts. By itself caesium therapy is capable of eradicating tumour in breast and axilla in half of the cases. It really amounts to a "double chance strategy"--an attempt at cure if possible with avoidance of mastectomy, this being in reserve in the event of failure.

[Telethermographic follow-up of breast cancers treated by radiotherapy]. / La surveillance téléthermographique des cancers du sein irradiés

The study of 635 breast cancers before and after radical radiation therapy, allows us to define 4 different ways of evolution: progressive linear cooling or sterilization, persistent thermal abnormalities or non-sterilization, relighting following a cooling phase or recurrence, persistent tepid breasts, meaning a radiation sequela (radiotherapic breast). We must emphasize that telethermography allows us to define the opportunity and timing of secondary surgery.