Is less than mastectomy a safe option?

Studies of the curability of breast cancer are reviewed. Of patients presenting with early disease, who are treated by ablative surgery, with or without postoperative radiotherapy, the proportion cured is small, with estimates of that proportion ranging from 0-30%. This fact must seriously modify arguments that failure to carry out a particular form of local treatment jeopardizes an individual patient's chances of cure. Techniques now exist whereby the breast can be conserved with acceptable cosmetic results in up to 90% of patients and with a salvage mastectomy rate of 10-15% at 10 years. These techniques can safely be applied to patients with tumours up to 5 cm in diameter whether or not homolateral nodes are palpable. Both survival rates and local recurrence rates are equivalent to those obtained by more radical surgery. Data from two clinical trials and numerous uncontrolled studies are reviewed and support these conclusions. A rigid application of a policy of total mastectomy as recommended by the Consensus Development Conference cannot be justified by arguments that alternative treatment carries with it an increased risk of recurrence or death. Such arguments are not supported by the data available in the literature. Strict rules regarding tumour size or the palpability of axillary nodes, which make conservation a safe alternative to mastectomy, are equally illogical and are also not supported by the data available. True and valid consent by a patient to any procedure requires a fair discussion of alternatives. We believe that the evidence that less than mastectomy is a safe alternative to radical surgery is so strong every woman presenting with operable breast cancer is entitled to discuss this approach to her management.