Symposium on Surgical Practice at the University of Chicago Clinics
Results of the Treatment of Mammary Cancer at the University of Chicago, 1960-1969
Donald J. Ferguson, M.D./ and Paul Meier, Ph.D. t
It may be hoped that new discoveries over the next few years will make moot the current conflict over proper treatment of mammary cancer. Barring that fortunate circumstance, the best evidence we are likely to have continues to come from well-controlled clinical trialS. l • 2 Nonetheless, the multiplicity of combinations of operation and additional treatments makes it essential to report and analyze carefully the outcome in well documented series, if only to develop clues for the efficient planning of further trials. We present a preliminary report on our experience for patients treated at the University of Chicago during the decade 1960-1969. (Further detailed analyses will be reported in future publications.) Follow-up of the patients has been essentially complete (99 per cent) over the 5 to 15 year period since treatment, owing to a highly effective Tumor Registry supplementing the efforts of individual surgeons.
Patients All the patients admitted to the hospital from 1 January 1960 to 31 December 1969 with a first-time diagnosis of mammary cancer are listed in Table 1. Clinical staging was done according to the American TNM system. lO Of the 492 female patients with primary infiltrative mammary cancer, about half were in stage 1, one quarter in stage 2, and the remainder in stages 3 and 4. Three-quarters were Caucasian, the rest mostly Negro, and these proportions were nearly the same when calculated by stage groupings. Histologically, 98 per cent had infiltrating ductal carcinoma. There were five cases of infiltrating lobular carcinoma and two of intracystic carcinoma. In situ carcinoma was excluded. From the University of Chicago Pritzker School of Medicine, Chicago, Illinois 'Professor of Surgery tProfessor of Statistics and Pharmacological and Physiological Sciences
Surgical Clinics of North America- Vol. 56, No.1, February 1976
103
104
DONALD
J.
FERGUSON AND PAUL MEIER
Table 1. Total Admissions for First Treatment of Mammary Cancer, University of Chicago, 1960-1969 529
Patients admitted to the hospital Excluded from this study: Male patients Ductal carcinoma in situ Lobular carcinoma in situ Sarcoma of breast Carcinoma of skin of breast Stage 4 ca cervix also present No operation, stage 1 or 2 Total exclusions
7 11 9 5 1 1 3 37 492
Femaie patients with infiltrating carcinoma
Results of Treatment The survival rate for all female patients with invasive mammary cancer treated for the first time is given in Table 2. Three postoperative deaths are included. Survival rates for each stage are shown in Figure 1. The separation of stage 1 from stage 2 depended on whether the clinician preoperatively recorded palpable homolateral axillary nodes. The rate of disagreement between clinical staging and pathologic staging is shown in Table 3. Almost 40 per cent of clinical stage 1 patients were found to have at least one positive axillary node, and in 20 per cent of clinical stage 2 patients no positive nodes were found. PROCEDURES. The standard operation for patients with breast cancer at stage 1 or 2 at the Hospital of the University of Chicago since it opened in 1927 has been radical mastectomy. A few patients have been treated by less extensive procedures and, since 1960, a number have been treated by the extended radical operation. Confining our attention now to patients in stages 1 and 2, the distribution by type of operation is shown in Table 4. Approximately 20 per
Table 2. Survival of All Female Patients with Infiltrating Mammary Carcinoma, Stages 1 to 4-' YEARS AFTER
WITHDRAWN PER CENT
STANDARD
DIAGNOSIS
NO. ALIVE
NO. DIED
NO. LOST
ALIVE
SURVIVED
ERROR
1 2 3 4 5 6 7 8 9 10 11
492 448 394 355 314 289 258 221 184 136 111
44 54 39 41 24 21 16 9 8 4
0 0 0 0
0 0 0 0 0 9 21 28 38 21 111
91 80 72
1.3 1.8 2.0 2.1 2.2 2.2 2.3 2.3 2.3 2.4
1 0 0 2 0
64
59 55 51 49 47 45
105
MAMMARY CANCER RESULTS
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2
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4
5
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7
8
9
10
Years after operation
Figure 1. Survival rates for mammary cancer according to stage, all patients. Stage 1, top line; stage 4, bottom line.
cent were treated by extended radical, 70 per cent by standard radical, and 10 per cent by less extensive mastectomies. Comparisons of survival rates between these groups are, of course, clouded by the effects of selection for one or another operation (Table 5). It is especially the case that less than radical procedures were typically adopted for older or infirm patients, and thus the survival of this group is not at all comparable with those treated by radical procedures. The degree of selection between extended radical and standard radical mastectomy was considerably less. Patients over 70 years of age were excluded from the extended radical group. Of the 74 extended radical procedures, 50 were done consecutively by one surgeon without regard to extent of disease. The remaining 24 were done by other surgeons who sometimes chose the extended radical for patients with more advanced disease. Several surgeons modified the extended radical operation, described by Urban,s by not removing pleura or by not doing the resection en bloc. Thus, although somewhat favored in age (average age was 50 for extended radical, and 54 for standard radical), the ex-
Accuracy of Clinical Staging in Patients Treated by Modified Radical, Radical, and Extended Radical Mastectomy
Table 3.
PATHOLOGICAL STAGE
Clinical stage 1 Clinical stage 2
134 24
1
PATHOLOGICAL STAGE
81 91
2
ERROR IN CLINICAL STAGING
38 per cent 21 per cent
106
DONALD
Table 4.
J.
FERGUSON AND PAUL MEIER
Distribution of Operations for Patients in Stages 1 and 2 NO. OF CASES
PER CENT OF CASES
Radical mastectomy Extended radical mastectomy
243 74
68} 89 21
Modified radical mastectomy Simple mastectomy Tylectomy
13 23 4
~ }11
TYPE OF OPERATION
TOTAL
357
tended radical group included more clinically advanced cases (per cent in stage 2 was 52 for extended radical and 34 for standard radical). There were two postoperative deaths in the radical group and one in the extended radical, all included in the table. Of 129 patients treated by standard radical mastecRADIATION. tomy who were found to have positive axillary nodes, 56 were given postoperative radiotherapy and 73 were not (Table 6). (Two postoperative
Table 5. Survival of Patients in Stages 1 and 2 after Radical Mastectomy and Extended Radical Mastectomy WITHYEARS
NO.
NO.
NO.
DRAWN
POSTOP.
ALIVE
DIED
LOST
ALIVE
2 3 4 5 6 7 8 9 10
243 240 230 216 202 189 175 154 134 97 79
3 10 14 14 12 9 9 6 7 3
0 0 0 0
2 3 4 5 6 7 8 9 10
74 72 70 70 64 60 52 45 39 29 23
2 2 0 6 4 5 4 1 0
Radical mastectomy
11 Extended radical mastectomy
11
0 0 2 0
0 0 0 0 0 0 0 0 0 0
PER CENT STANDARD SURVIVED
ERROR
0 0 0 0 0 4 12 14 28 15 79
99 95 89 83 78 74 71 68 64 61
0.8 1.4 2.0 2.4 2.6 2.8 2.9 3.0 3.2 3.3
0 0 0 0 0 3 3 5 10 5 23
97 95 95 87 81 74 68 67 67 64
1.9 2.6 2.6 4.0 4.6 5.1 5.5 5.6 5.6 6.0
107
MAMMARY CANCER RESULTS
Table 6. Survival of Patients in Pathologic Stage 2, Treated by Radical Mastectomy with and without Postoperative Radiotherapy WITH-
No radiation
Postoperative radiation
YEARS
NO.
NO.
NO.
POSTOP.
ALIVE
DIED
LOST
ALIVE
1 2 3 4 5 6 7 8 9 10 11
56 56 49 43 40 36 33 25 20 12 8
0 7 6 3 3 3 3
0 0 0 0 1 0 0 0 1 0
0 0 0 0 0 0 5 4 5 4 8
100 88 77 66 60 54 52 46 46
4.8 5.6 6.0 6.3 6.6 6.8 6.9 7.3 7.3
1 2 3 4 5 6 7 8 9 10 11
73 73 69 63 55 49 45 39 38 31 28
0 0 0 0 0 1 0 0 1 0
0 0 0 0 0 0 3 1 5 2 28
100 95 86 75 67 63 58 58 57 55
2.7 4.1 5.1 5.5 5.7 5.8 5.8 5.9 6.0
2 0
0 4 6 8 6 3 3 0
DRAWN PER CENT STANDARD SURVIVED
71
ERROR
deaths are omitted.) The choice was generally made according to the surgeon's routine, rather than by indications found in individual patients. Patients received treatment from a 250 kv machine over a period of 12 weeks, totaling 6000 rads to each tissue through 5 ports, covering the supraclavicular and internal mammary areas in addition to the operative site.
Results and Discussion What do our data show? Within the operable stages 1 and 2, the only groups substantial enough to be compared are those with standard radical mastectomy vs. extended radical, and those with or without postoperative radiotherapy after radical mastectomy. It is clear from Table 5 that the survival results from extended radical and standard radical mastectomy are very similar-a difference of only 3 per cent in favor of the extended procedure, which is negligible compared to its standard error. The difference between irradiated and nonirradiated subjects is 1 per cent in favor of irradiation at 5 years and 9 per cent at 10 years, but even the larger difference is smaller than its standard error (see Table 6). Thus, there is no clear evidence from our data for or against either therapeutic choice.
108
DONALD
J.
FERGUSON AND PAUL MEIER
Table 7. Comparison of Survival Rates for Purportedly Unselected Groups of Women Treated at all Stages When First Seen for Infiltrating Mammary Carcinoma
Number of patients Per cent 5-year survivals Per cent 10-year survivals Per cent of patients stage 1-2
SCOTLAND"
CHICAGO
SASKATCHEWAN'
NEW YORK'
1941-1947
1960-1969
1952-1959
1935-1963
1882 42 25 57
492 59 45 73
1510 58 76
1076 51 82
How do our survival rates compare with those of other institutions? In Table 7 are shown our overall results, along with those for three other institutions, for purportedly unselected groups of women treated at all stages when first seen for infiltrating mammary carcinoma. It appears that the results correlate, as might be expected, with the proportion of patients first seen at an early stage. Otherwise, the overall results of the four institutions seem generally comparable. Should a policy of routine radical mastectomy be changed? Our results for radical surgery at stages one and two average about 80 per cent 5-year survival, which appear somewhat more favorable than those reported in five major series using tylectomy or simple mastectomy, namely, 71,67,65,61, and 58 per cent (Atkins,! Crile,3 Porritt,S Kaae and Johansen,S and Brinkley and Haybittle,2 respectively). We recognize, however, that variations between institutions are large for a variety of reasons, including differences in details of procedure, completeness of follow-up, populations from which cases are drawn, and many other factors. No claim of superiority is made on the basis of the above findings. At the same time, the comparison does not reflect unfavorably on our present practice. Among several controlled studies comparing radical and less extensive procedures, Atkins et al. 1 showed that, although the overall results for operable cases were comparable as between tylectomy and radical surgery, there was a potentially substantial difference in favor of radical surgery when the comparison is restricted to clinical stage 2 cases. Although no difference in survival at 5 and 10 years was found in clinical stage 1 cases, positive axillary nodes were found in 24 per cent of stage 1 cases subjected to radical surgery. What reasons are there to favor the extended radical mastectomy over the standard radical? Our survival rates show no noticeable difference between the two, but we do have the evidence of six of the 74 cases treated by extended radical who had positive internal mammary nodes, yet remain well for periods of follow-up ranging from 5 to 12 years. It must be expected that not all are in fact disease-free and thus the logically hoped for improvement in end-results by this additional surgery must be small-in the range of 5 per cent. The number of patients required to establish this difference, even if all of our patients could be entered into a randomized trial, is beyond our presently en-
109
MAMMARY CANCER RESULTS
visioned resources. However, our surgical morbidity in the extended radical procedure seems no worse than that for the standard radical and so long as we take the surgeon's objective to be the complete surgical extirpation of disease, within the constraint of acceptable surgical morbidity, the extended radical mastectomy appears, on our evidence, to remain a reasonable choice. In connection with the choice of extended radical mastectomy for patients in stage 1, it may be noted that five of our six long-term survivors with metastases in internal mammary nodes were in clinical stage 1. ACKNOWLEDGMENTS
The excellent cooperation of the University of Chicago Tumor Registry, supervised by Mrs. Florence Lowenstein, was indispensable in this study. Mrs. Millie Faulkner, Medical Records, was exceptionally helpful. Support for this research has been provided in part by National Science Foundation Research Grants No. MPS 72-04364 A03 and No. Soc 72-05228 A03.
REFERENCES 1. Atkins, H., Hayward, J. L., Klugman, D. J., and Wayte, A. B.: Treatment of early breast cancer: a report after ten years of a clinical trial. Br. Med. J., 2:423-429, 1972. 2. Brinkley, D., and Haybittle, J. L.: Treatment of stage II carcinoma of the female breast. Lancet, 2:1086-7,1971. 3. Crile, G., and Hoerr, S. 0.: Results of treatment of carcinoma of the breast by local excision. Surg. Gynec. Obstet., 132:780-782, 1971. 4. Haagensen, C. D.: The choice of treatment for operable carcinoma of the breast. Surgery, 76:685-714,1974. 5. Kaae, S., and Johansen, H.: Breast cancer. Five year results: two random series of simple mastectomy with postoperative irradiation versus extended radical mastectomy. Am. J. Roentgen., 87:82-88, 1962. 6. McWhirter, R.: Simple mastectomy and radiotherapy in the treatment of breast cancer. Br. J. Rad., 28:128-139, 1955. 7. Porritt, A.: Early carcinoma of the breast. Br. J. Surg., 51 :214-216, 1964. 8. Urban, J. A.: Radical mastectomy in continuity with en bloc resection of the internal mammary lymph-node chain. Cancer, 5:992-1008, 1952. 9. Watson, T. A.: Cancer of the breast. Am. J. Roentgen., 96:547-559,1966. 10. Zippin, C.: Comparison of the International and American systems for the staging of breast cancer. J. Natl. Cancer Instit., 36:53-62, 1966. Department of Surgery University of Chicago Pritzker School of Medicine 950 East 59th Street Chicago, Illinois 60637
Results of the Treatment of Mammary Cancer at the University of Chicago, 1960-1969
Donald J. Ferguson, M.D./ and Paul Meier, Ph.D. t
It may be hoped that new discoveries over the next few years will make moot the current conflict over proper treatment of mammary cancer. Barring that fortunate circumstance, the best evidence we are likely to have continues to come from well-controlled clinical trialS. l • 2 Nonetheless, the multiplicity of combinations of operation and additional treatments makes it essential to report and analyze carefully the outcome in well documented series, if only to develop clues for the efficient planning of further trials. We present a preliminary report on our experience for patients treated at the University of Chicago during the decade 1960-1969. (Further detailed analyses will be reported in future publications.) Follow-up of the patients has been essentially complete (99 per cent) over the 5 to 15 year period since treatment, owing to a highly effective Tumor Registry supplementing the efforts of individual surgeons.
Patients All the patients admitted to the hospital from 1 January 1960 to 31 December 1969 with a first-time diagnosis of mammary cancer are listed in Table 1. Clinical staging was done according to the American TNM system. lO Of the 492 female patients with primary infiltrative mammary cancer, about half were in stage 1, one quarter in stage 2, and the remainder in stages 3 and 4. Three-quarters were Caucasian, the rest mostly Negro, and these proportions were nearly the same when calculated by stage groupings. Histologically, 98 per cent had infiltrating ductal carcinoma. There were five cases of infiltrating lobular carcinoma and two of intracystic carcinoma. In situ carcinoma was excluded. From the University of Chicago Pritzker School of Medicine, Chicago, Illinois 'Professor of Surgery tProfessor of Statistics and Pharmacological and Physiological Sciences
Surgical Clinics of North America- Vol. 56, No.1, February 1976
103
104
DONALD
J.
FERGUSON AND PAUL MEIER
Table 1. Total Admissions for First Treatment of Mammary Cancer, University of Chicago, 1960-1969 529
Patients admitted to the hospital Excluded from this study: Male patients Ductal carcinoma in situ Lobular carcinoma in situ Sarcoma of breast Carcinoma of skin of breast Stage 4 ca cervix also present No operation, stage 1 or 2 Total exclusions
7 11 9 5 1 1 3 37 492
Femaie patients with infiltrating carcinoma
Results of Treatment The survival rate for all female patients with invasive mammary cancer treated for the first time is given in Table 2. Three postoperative deaths are included. Survival rates for each stage are shown in Figure 1. The separation of stage 1 from stage 2 depended on whether the clinician preoperatively recorded palpable homolateral axillary nodes. The rate of disagreement between clinical staging and pathologic staging is shown in Table 3. Almost 40 per cent of clinical stage 1 patients were found to have at least one positive axillary node, and in 20 per cent of clinical stage 2 patients no positive nodes were found. PROCEDURES. The standard operation for patients with breast cancer at stage 1 or 2 at the Hospital of the University of Chicago since it opened in 1927 has been radical mastectomy. A few patients have been treated by less extensive procedures and, since 1960, a number have been treated by the extended radical operation. Confining our attention now to patients in stages 1 and 2, the distribution by type of operation is shown in Table 4. Approximately 20 per
Table 2. Survival of All Female Patients with Infiltrating Mammary Carcinoma, Stages 1 to 4-' YEARS AFTER
WITHDRAWN PER CENT
STANDARD
DIAGNOSIS
NO. ALIVE
NO. DIED
NO. LOST
ALIVE
SURVIVED
ERROR
1 2 3 4 5 6 7 8 9 10 11
492 448 394 355 314 289 258 221 184 136 111
44 54 39 41 24 21 16 9 8 4
0 0 0 0
0 0 0 0 0 9 21 28 38 21 111
91 80 72
1.3 1.8 2.0 2.1 2.2 2.2 2.3 2.3 2.3 2.4
1 0 0 2 0
64
59 55 51 49 47 45
105
MAMMARY CANCER RESULTS
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2
3
4
5
6
7
8
9
10
Years after operation
Figure 1. Survival rates for mammary cancer according to stage, all patients. Stage 1, top line; stage 4, bottom line.
cent were treated by extended radical, 70 per cent by standard radical, and 10 per cent by less extensive mastectomies. Comparisons of survival rates between these groups are, of course, clouded by the effects of selection for one or another operation (Table 5). It is especially the case that less than radical procedures were typically adopted for older or infirm patients, and thus the survival of this group is not at all comparable with those treated by radical procedures. The degree of selection between extended radical and standard radical mastectomy was considerably less. Patients over 70 years of age were excluded from the extended radical group. Of the 74 extended radical procedures, 50 were done consecutively by one surgeon without regard to extent of disease. The remaining 24 were done by other surgeons who sometimes chose the extended radical for patients with more advanced disease. Several surgeons modified the extended radical operation, described by Urban,s by not removing pleura or by not doing the resection en bloc. Thus, although somewhat favored in age (average age was 50 for extended radical, and 54 for standard radical), the ex-
Accuracy of Clinical Staging in Patients Treated by Modified Radical, Radical, and Extended Radical Mastectomy
Table 3.
PATHOLOGICAL STAGE
Clinical stage 1 Clinical stage 2
134 24
1
PATHOLOGICAL STAGE
81 91
2
ERROR IN CLINICAL STAGING
38 per cent 21 per cent
106
DONALD
Table 4.
J.
FERGUSON AND PAUL MEIER
Distribution of Operations for Patients in Stages 1 and 2 NO. OF CASES
PER CENT OF CASES
Radical mastectomy Extended radical mastectomy
243 74
68} 89 21
Modified radical mastectomy Simple mastectomy Tylectomy
13 23 4
~ }11
TYPE OF OPERATION
TOTAL
357
tended radical group included more clinically advanced cases (per cent in stage 2 was 52 for extended radical and 34 for standard radical). There were two postoperative deaths in the radical group and one in the extended radical, all included in the table. Of 129 patients treated by standard radical mastecRADIATION. tomy who were found to have positive axillary nodes, 56 were given postoperative radiotherapy and 73 were not (Table 6). (Two postoperative
Table 5. Survival of Patients in Stages 1 and 2 after Radical Mastectomy and Extended Radical Mastectomy WITHYEARS
NO.
NO.
NO.
DRAWN
POSTOP.
ALIVE
DIED
LOST
ALIVE
2 3 4 5 6 7 8 9 10
243 240 230 216 202 189 175 154 134 97 79
3 10 14 14 12 9 9 6 7 3
0 0 0 0
2 3 4 5 6 7 8 9 10
74 72 70 70 64 60 52 45 39 29 23
2 2 0 6 4 5 4 1 0
Radical mastectomy
11 Extended radical mastectomy
11
0 0 2 0
0 0 0 0 0 0 0 0 0 0
PER CENT STANDARD SURVIVED
ERROR
0 0 0 0 0 4 12 14 28 15 79
99 95 89 83 78 74 71 68 64 61
0.8 1.4 2.0 2.4 2.6 2.8 2.9 3.0 3.2 3.3
0 0 0 0 0 3 3 5 10 5 23
97 95 95 87 81 74 68 67 67 64
1.9 2.6 2.6 4.0 4.6 5.1 5.5 5.6 5.6 6.0
107
MAMMARY CANCER RESULTS
Table 6. Survival of Patients in Pathologic Stage 2, Treated by Radical Mastectomy with and without Postoperative Radiotherapy WITH-
No radiation
Postoperative radiation
YEARS
NO.
NO.
NO.
POSTOP.
ALIVE
DIED
LOST
ALIVE
1 2 3 4 5 6 7 8 9 10 11
56 56 49 43 40 36 33 25 20 12 8
0 7 6 3 3 3 3
0 0 0 0 1 0 0 0 1 0
0 0 0 0 0 0 5 4 5 4 8
100 88 77 66 60 54 52 46 46
4.8 5.6 6.0 6.3 6.6 6.8 6.9 7.3 7.3
1 2 3 4 5 6 7 8 9 10 11
73 73 69 63 55 49 45 39 38 31 28
0 0 0 0 0 1 0 0 1 0
0 0 0 0 0 0 3 1 5 2 28
100 95 86 75 67 63 58 58 57 55
2.7 4.1 5.1 5.5 5.7 5.8 5.8 5.9 6.0
2 0
0 4 6 8 6 3 3 0
DRAWN PER CENT STANDARD SURVIVED
71
ERROR
deaths are omitted.) The choice was generally made according to the surgeon's routine, rather than by indications found in individual patients. Patients received treatment from a 250 kv machine over a period of 12 weeks, totaling 6000 rads to each tissue through 5 ports, covering the supraclavicular and internal mammary areas in addition to the operative site.
Results and Discussion What do our data show? Within the operable stages 1 and 2, the only groups substantial enough to be compared are those with standard radical mastectomy vs. extended radical, and those with or without postoperative radiotherapy after radical mastectomy. It is clear from Table 5 that the survival results from extended radical and standard radical mastectomy are very similar-a difference of only 3 per cent in favor of the extended procedure, which is negligible compared to its standard error. The difference between irradiated and nonirradiated subjects is 1 per cent in favor of irradiation at 5 years and 9 per cent at 10 years, but even the larger difference is smaller than its standard error (see Table 6). Thus, there is no clear evidence from our data for or against either therapeutic choice.
108
DONALD
J.
FERGUSON AND PAUL MEIER
Table 7. Comparison of Survival Rates for Purportedly Unselected Groups of Women Treated at all Stages When First Seen for Infiltrating Mammary Carcinoma
Number of patients Per cent 5-year survivals Per cent 10-year survivals Per cent of patients stage 1-2
SCOTLAND"
CHICAGO
SASKATCHEWAN'
NEW YORK'
1941-1947
1960-1969
1952-1959
1935-1963
1882 42 25 57
492 59 45 73
1510 58 76
1076 51 82
How do our survival rates compare with those of other institutions? In Table 7 are shown our overall results, along with those for three other institutions, for purportedly unselected groups of women treated at all stages when first seen for infiltrating mammary carcinoma. It appears that the results correlate, as might be expected, with the proportion of patients first seen at an early stage. Otherwise, the overall results of the four institutions seem generally comparable. Should a policy of routine radical mastectomy be changed? Our results for radical surgery at stages one and two average about 80 per cent 5-year survival, which appear somewhat more favorable than those reported in five major series using tylectomy or simple mastectomy, namely, 71,67,65,61, and 58 per cent (Atkins,! Crile,3 Porritt,S Kaae and Johansen,S and Brinkley and Haybittle,2 respectively). We recognize, however, that variations between institutions are large for a variety of reasons, including differences in details of procedure, completeness of follow-up, populations from which cases are drawn, and many other factors. No claim of superiority is made on the basis of the above findings. At the same time, the comparison does not reflect unfavorably on our present practice. Among several controlled studies comparing radical and less extensive procedures, Atkins et al. 1 showed that, although the overall results for operable cases were comparable as between tylectomy and radical surgery, there was a potentially substantial difference in favor of radical surgery when the comparison is restricted to clinical stage 2 cases. Although no difference in survival at 5 and 10 years was found in clinical stage 1 cases, positive axillary nodes were found in 24 per cent of stage 1 cases subjected to radical surgery. What reasons are there to favor the extended radical mastectomy over the standard radical? Our survival rates show no noticeable difference between the two, but we do have the evidence of six of the 74 cases treated by extended radical who had positive internal mammary nodes, yet remain well for periods of follow-up ranging from 5 to 12 years. It must be expected that not all are in fact disease-free and thus the logically hoped for improvement in end-results by this additional surgery must be small-in the range of 5 per cent. The number of patients required to establish this difference, even if all of our patients could be entered into a randomized trial, is beyond our presently en-
109
MAMMARY CANCER RESULTS
visioned resources. However, our surgical morbidity in the extended radical procedure seems no worse than that for the standard radical and so long as we take the surgeon's objective to be the complete surgical extirpation of disease, within the constraint of acceptable surgical morbidity, the extended radical mastectomy appears, on our evidence, to remain a reasonable choice. In connection with the choice of extended radical mastectomy for patients in stage 1, it may be noted that five of our six long-term survivors with metastases in internal mammary nodes were in clinical stage 1. ACKNOWLEDGMENTS
The excellent cooperation of the University of Chicago Tumor Registry, supervised by Mrs. Florence Lowenstein, was indispensable in this study. Mrs. Millie Faulkner, Medical Records, was exceptionally helpful. Support for this research has been provided in part by National Science Foundation Research Grants No. MPS 72-04364 A03 and No. Soc 72-05228 A03.
REFERENCES 1. Atkins, H., Hayward, J. L., Klugman, D. J., and Wayte, A. B.: Treatment of early breast cancer: a report after ten years of a clinical trial. Br. Med. J., 2:423-429, 1972. 2. Brinkley, D., and Haybittle, J. L.: Treatment of stage II carcinoma of the female breast. Lancet, 2:1086-7,1971. 3. Crile, G., and Hoerr, S. 0.: Results of treatment of carcinoma of the breast by local excision. Surg. Gynec. Obstet., 132:780-782, 1971. 4. Haagensen, C. D.: The choice of treatment for operable carcinoma of the breast. Surgery, 76:685-714,1974. 5. Kaae, S., and Johansen, H.: Breast cancer. Five year results: two random series of simple mastectomy with postoperative irradiation versus extended radical mastectomy. Am. J. Roentgen., 87:82-88, 1962. 6. McWhirter, R.: Simple mastectomy and radiotherapy in the treatment of breast cancer. Br. J. Rad., 28:128-139, 1955. 7. Porritt, A.: Early carcinoma of the breast. Br. J. Surg., 51 :214-216, 1964. 8. Urban, J. A.: Radical mastectomy in continuity with en bloc resection of the internal mammary lymph-node chain. Cancer, 5:992-1008, 1952. 9. Watson, T. A.: Cancer of the breast. Am. J. Roentgen., 96:547-559,1966. 10. Zippin, C.: Comparison of the International and American systems for the staging of breast cancer. J. Natl. Cancer Instit., 36:53-62, 1966. Department of Surgery University of Chicago Pritzker School of Medicine 950 East 59th Street Chicago, Illinois 60637
