The researchers are definitely not saying that breast conservation treatment should be used less in younger patients, but they are saying that extra care should be taken with this treatment in younger women and that they should be followed up indefinitely. They also emphasised that the patients in their research study were diagnosed in the 1970s and therefore did not receive tamoxifen - the anti-oestrogen drug now widely given to women whose tumours are hormone-sensitive.
The study, by a team from the Institut Gustave-Roussy and INSERM in Villejuif, France, followed 179 patients recruited to a trial in the 1970s for a mean duration of 22 years after diagnosis - the longest follow-up of any trial comparing lumpectomy with breast irradiation against mastectomy. The 91 mastectomy and 88 conservation treatment patients were comparable in terms of age, tumour size (under 20 mm) and grade and the number of negative lymph nodes.
To verify the validity of their findings the researchers then analysed the results of 1,847 patients from the Institut Gustave-Roussy's database (632 who had conservation surgery and 1,215 who had mastectomies) who also had small tumours (under 25mm) and had followed a comparable radiotherapy protocol.
"What we found in the trial of 179 patients was that there was no difference over time on survival or on metastasis (secondary cancer)," said lead researcher Dr Rodrigo Arriagada. "The risk of local recurrence was actually five-fold less in the breast conservation patients during the first five years than in the mastectomy group. However, after five years it was 12-fold greater. The age range of the patients who developed local recurrence was similar between the two groups during the first five years - 57 in the conservation group and 53 in the mastectomy group. But, the mean age of patients in the conservation group who had local recurrence after 5-10 years was 46 and after 10 years it was 44. The only patient who had a local recurrence in the mastectomy group after five years was aged 59.
"We found a similar result in the database patients. Late breast recurrence was more frequent in the conservation group and the effect was even greater among patients who were under 40 when they were diagnosed. The whole difference in local recurrence between those who had conserving surgery and those who had mastectomies occurred after 10-15 years. Fifteen years after diagnosis, for those aged over 61 the incidence of local recurrence and contralateral breast cancer was 12% in both conservation and mastectomy groups. For 51 to 60 year-olds it was 12% in the conservation group and 5% in the mastectomy group. For 41 to 50-year olds it was 13% in the conservation group and 7% in the mastectomy group and for women up to 40 it was 36% in the conservation group and 12% in the mastectomy group.
"All these results were observed in patients who did not receive adjuvant treatment with tamoxifen, an anti-oestrogen that has been shown to have a beneficial effect on local control for patients with hormone-responsive tumours".
Dr Arriagada is a consultant radiation oncologist at the Instituto de Radiomedicina in Santiago, Chile, but worked for 25 years at the Institut Gustave-Roussy and spends long periods undertaking clinical research there as an invited professor. He said: "Our results confirm that a young age at diagnosis is a strong prognostic factor for local recurrence in breast conservation patients and not in patients treated by mastectomy.
"If these results are corroborated, younger patients should be informed of the higher risk of local recurrence and the need for indefinite follow up if they choose conservation treatment. However, this higher risk does not decrease the probabilities of long-term cure, as overall survival is the same, independently of the initial surgery performed. Indeed, local recurrence after breast-conserving surgery may be successfully treated if there is early diagnosis."
He said that a cautious approach should be taken for younger women - wider margins to the lumpectomy, the placing of surgical clips in the tumour bed to improve the accuracy of radiotherapy, a good radiotherapy boost technique and the addition of tamoxifen in patients with hormone-responsive tumours. The European Organisation for Research and Treatment of Cancer (EORTC) was, he added, currently planning a new trial to evaluate the role of higher boost doses in younger patients.
Dr Arriagada stressed that the findings did not indicate that young patients should opt for mastectomy. "We should not forget that the increased risk after 15 years is limited - 20 to 25%. If a young patient of 35 is able to conserve an aesthetic breast for this time maybe the impact on her quality of life will be a little bit less at 55 years, and in any case three women out of four will be free of local recurrence. This information should be given to patients to enable them to choose between breast conserving surgery and mastectomy with breast reconstruction. We should also be aware that recent developments in genomic techniques could in the future allow the risk of local recurrence among these younger women to be defined more accurately."
 Late local recurrences in a randomised trial comparing conservative treatment with total mastectomy in early breast cancer patients. Annals of Oncology. Vol. 14. No 11. Pp 1617-1622.
1 Annals of Oncology is the monthly journal of the European Society for Medical Oncology. Please acknowledge the journal as the source in any reports.
2 Annals of Oncology website: http://www.
3 PDF of article available from Margaret Willson
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