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rarely present Skin-sparing mastectomy is currently gaining favor but is not appropriate for all patients Radiotherapy after partial mastectomy consists of 5 6 weeks of five daily fractions to a total dose of 5000 6000 cGy Most radiation oncologists use a boost dose to the cancer location Several studies are underway examining the utility and recurrence rates after intraoperative radiation or dose dense radiation in which the time course of radiation is shortened Accelerated partial breast irradiation, in which only the portion of the breast from which the tumor was resected is irradiated for 1 2 weeks, appears effective in achieving local control A prospective randomized trial to examine the efficacy of this technique is underway Current studies suggest that radiotherapy after mastectomy may improve survival in a subset of patients and is being further researched in a large cooperative trial to better identify which subgroups will benefit Researchers are also examining the utility of axillary irradiation as an alternative to axillary dissection in the clinically nodenegative patient with sentinel node micrometastases Preoperatively, full discussion with the patient regarding the rationale for operation and various alternative forms of treatment is essential Breast-conserving surgery and radiation should be offered whenever possible, since most patients would prefer to save the breast Breast reconstruction, immediate or delayed, should be discussed with patients who choose or require mastectomy Patients should have an interview with a reconstructive plastic surgeon to discuss options prior to making a decision regarding reconstruction Time is well spent preoperatively in educating the patient and family about these matters
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D Adjuvant Systemic Therapy
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1 Chemotherapy Following surgery and possible radiation therapy, systemic therapy improves survival and is advocated for most patients with curable breast cancer The objective of adjuvant systemic therapy is to eliminate occult metastases in distant organs while they are microscopic and most vulnerable In addition, chemotherapy may decrease local recurrence in patients treated with breast conservation, whereas hormonal manipulation decreases contralateral breast cancer occurrence as well as ipsilateral recurrence A landmark study from Milan, Italy evaluating the effect of adjuvant chemotherapy, cyclophosphamide, methotrexate, and fluorouracil (CMF), given for 12 months showed a significant improvement in survival, which persisted at 20 years follow-up, for premenopausal women with node-positive disease Subsequently, the use of chemotherapy for postmenopausal women and those at less risk than node-positive women was evaluated Systemic chemotherapy improves survival in all groups of women treated The improvement in survival appears to be about 30% of the patients risk of death; that is, a woman with a 30% chance of recurrence and death derives about a 10% overall improvement in survival This risk reduction analysis has been confirmed in numerous studies and meta-analyses On the basis of the superiority of anthracycline-containing regimens in metastatic breast cancer, both doxoru-
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Earlier consensus held that breast-conserving surgery with radiation was the preferred form of treatment for patients with early-stage breast cancer Despite the numerous randomized trials showing no survival benefit of mastectomy over breast-conserving partial mastectomy and irradiation, breast-conserving surgery appears underutilized Modified radical mastectomy has been the standard therapy for most patients with early-stage breast cancer This operation removes the entire breast, overlying skin, nipple, and areolar complex as well as the underlying pectoralis fascia with the axillary lymph nodes in continuity The major advantage of modified radical mastectomy is that radiation therapy may not be necessary, although radiation may be used when multiple lymph nodes are involved with cancer The disadvantage of mastectomy is the cosmetic and psychological impact associated with breast loss Radical mastectomy, which removes the underlying pectoralis muscle, should be performed rarely, if at all Axillary node dissection is not indicated for noninfiltrating cancers because nodal metastases are
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