Mastectomy or lumpectomy? The choice of operation for clinical stages I and II breast cancer. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists.

OBJECTIVE

To assist women and their physicians in making the most clinically effective and personally acceptable decision regarding the choice of primary surgery for potentially curable breast cancer.

OPTIONS

Breast-conserving surgery (BCS; also referred to as lumpectomy or wide local excision) or mastectomy.

OUTCOMES

Local recurrence, metastasis-free survival, overall survival, cosmetic results.

EVIDENCE

Systematic computerized citation search using MEDLINE (from 1980) and CANCERLIT (from 1985) databases to September 1995. Nonsystematic review of breast cancer literature until January 1997.

BENEFITS

Minimization of disfigurement offered by BCS.

HARMS

The need for radiotherapy and the greater costs associated with BCS.

RECOMMENDATIONS

For patients with stage I or II breast cancer, BCS followed by radiotherapy is generally recommended. In the absence of special reasons for selecting mastectomy, the choice between BCS and mastectomy can be made according to the patient's circumstances and personal preferences. Mastectomy should be considered in the presence of any of the following: (a) factors that increase the risk of local recurrence such as extensive malignant-type calcifications visible on the mammogram, multiple primary tumours or failure to obtain tumour-free margins; (b) physical disabilities that preclude lying flat or abducting the arm, preventing the use of radiotherapy; (c) absolute contraindications for radiotherapy such as pregnancy or previous irradiation of the breast or relative contraindications such as systemic lupus erythematosus or scleroderma; (d) large tumour size in proportion to breast size; (e) the patient's clear preference for mastectomy. The following factors are not contraindications for BCS: the presence of a centrally located tumour mass, axillary lymph-node involvement or the presence of breast implants. Before deciding between BCS and mastectomy, the physician must make a full and balanced presentation to the patient concerning the pros and cons of these procedures. Whenever an open biopsy is performed on the basis of even modest suspicion of carcinoma, the procedure should be, in effect, a lumpectomy, using wide local excision of the intact tumour surrounded by a cuff of tumour-free tissue (by palpation and visual inspection). The following recommendations should be observed to provide optimum clinical and cosmetic results: (a) Tumour-involved margins should be revised; (b) Separate incisions should be used for removal of the primary tumour and for the axillary dissection except when these coincide anatomically; (c) Radial incisions should not be used except when directly medial or lateral to the nipple; (d) Drains and approximation sutures should not be used in the breast parenchyma.

VALIDATION

Guidelines were reviewed and revised by the Writing Committee, expert primary reviewers, secondary reviewers selected from all regions of Canada and by the Steering Committee. The final document reflects a consensus of all these contributors and has +been endorsed by the Canadian Association of Radiation Oncologists.