Patey’s Mastectomy Patey’s (Radical) Mastectomy Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales) MMSc (Newcastle) Professor of Surgery Department of Surgery King George’s Medical University Lucknow, 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 Breast cancer : the survival Local treatment + Systemic treatment Survival Adjuvant radiotherapy Survival Overgaard et al, NEJM 1997; 337:949 Ragaz et al, NEJM 1997; 337:956 Hellman S, NEJM 1997; 337:996 Radical surgical treatment Survival Quality of life Conservation Technique Seek LRR Require intensive radiotherapy Chemotherapy Long term follow-up monitoring Psychological Benefits of Conservation Radiotherapy Outcome Chemotherapy Is this really good s or as hoped ss 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 Size Tumor Conservatively treated size Radically treated No Alive Percent Median survival (mo) No Alive Percent Median survival (mo) P value T1 49 / 81 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 60.4 % >132 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 Summary Radical 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 included in studies in which surgery is a component of therapy David Patey