Departments and Specialties

The Jacqueline M. Wilentz Comprehensive Breast Center

Breast Conservation Surgery

Recently two landmark studies that followed women for 20 years after breast cancer surgery confirmed that breast conservation surgery is an effective treatment alternative to radical mastectomy for early cancers

At Monmouth Medical Center, results of a nearly 10-year study of women treated with breast conservation surgery have supported these findings, revealing a local recurrence rate of only one out of 256 patients.

According to Michael Goldfarb, M.D., FACS, Monmouth Medical Center’s chairman and program director for the Department of Surgery and surgical coordinator for the Jacqueline M. Wilentz Comprehensive Breast Center, the emphasis of the hospital’s breast surgery program is on breast conservation surgery for women with Stage I or Stage II cancers. In addition to Dr. Goldfarb, the center’s team of surgeons include David Averbach, M.D., Debra Camal, M.D., Enrique DeVoto, M.D., Ernest Ginalis, M.D., Aron Gornish, M.D., and Mark Schwartz, M.D.

“The key thing about the comprehensive breast center is the efficacy and the results of the multidisciplinary team approach,” Dr. Goldfarb says. “We’ve just put together data from 1994 — when the breast center opened — through 2002, analyzing 464 breast center patients who have had surgery. Some patients had bilateral disease or needed more than one operation to obtain clear margins.” According to Dr. Goldfarb, the patients range in age from 27 to 89. Eighty-two percent had invasive carcinoma on initial biopsy.

“The emphasis of the surgical approach is to try to do conservation surgery and to avoid performing a mastectomy, but because we are a referral center, we see many advanced cases, so 230 of these patients did have some form of mastectomy performed for large tumors or multifocal disease,” he says.

Numerous studies have been done in this country and abroad comparing modified radical mastectomy and breast conservation surgery. A statement made in 1990 by the National Cancer Institute Consensus Conference on the Treatment of Breast Cancer clarified this by concluding that "breast conservation treatment is an appropriate method of primary therapy for a majority of women with stage 1 or 2 breast cancer, and preferable because it provides survival equivalent to total mastectomy and an axillary dissection while preserving the breast." Most recently, two studies appeared in The New England Journal of Medicine reporting that two different breast-conserving surgeries have the same 20-year survival rates as the previous gold standard, the modified radical mastectomy, confirming what had been a widely held belief in the medical community — that breast conservation is equivalent to mastectomy in terms of survival. The first study, led by Umberto Veronesi, M.D., of the European Institute of Oncology in Milan, Italy, and the first randomized trial of mastectomy versus breast conservation, looked at 701 women who were randomly assigned to receive a radical mastectomy or breast conservation surgery. Although the rate of local recurrence was higher in women who underwent a lumpectomy, there was little difference in the incidence of metastasis -- or spread -- of the cancer. As a result, the overall survival rate was virtually identical among women in the two groups, the researchers say.

Today, after more than 20 years, the long-term follow-up of the women in the Italian study points to success rates for breast-conservation surgery that are identical to that of mastectomy patients.

The second study, known as trial B-06, was conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) in Pittsburgh. Also a 20-year follow-up study, it compared modified radical mastectomy with lumpectomy, with and without radiation. Among 1,851 women randomly assigned to one of three treatment groups (total mastectomy, lumpectomy alone or lumpectomy with radiation), those receiving lumpectomy with breast irradiation had the lowest incidence of a recurrence in the same breast.

“Internationally, studies show a 5 percent to 30 percent local recurrence rate for breast conservation surgery,” he says. “But at Monmouth, we’ve had a 0.4 percent recurrent rate — representing just one patient.”

Dr. Goldfarb attributes this remarkable success rate to a requirement at Monmouth that surgeons ensure a .5-centimeter margin of uninvolved breast tissue around every border of the tumor. Additionally, breast conservation surgery usually is followed by radiation therapy to eradicate any residual cancer.

“Our surgeons perform a segmentectomy or quadrantectomy rather than a lumpectomy, where only a small margin is removed with the tumor,” he says. “We insist on securing clean margins. When the margin is less than .5 centimeters and we re-operate and take more tissue to get a wider margin, about 30 percent of the time pathology reveals more tumor. That’s why our results are so impressive; we simply take a lot more tissue and have wider clear margins.” Additionally, Dr. Goldfarb points to the study’s look at the center’s protocol-tested sentinel lymph node biopsy program, which began in August, 1999. This procedure allows surgeons to sample the fist draining lymph node and, in the majority of cases spare women the removal of the entire cluster of lymph nodes and the complications that often accompany this procedure — and is a further example of the outstanding results of Monmouth’s breast conservation approach, he says.

“Our data indicates that if the tumor is less than 2 centimeters (under an inch), there is a 23 percent chance of finding positive lymph nodes,” he says. “This means that in this group, 77 percent of the patients will be spared the removal of the lymph nodes cluster under their arm, and thus will be spared possible subsequent arm swelling, numbness and stiffness in the arm.”

If the tumor is more than 2 centimeters, 60 percent of the patients will be spared axillary dissection, according to Dr. Goldfarb, who led sentinel lymph node study at Monmouth. “Of the total number of patients, 165 underwent sentinel lymph node biopsy, and 75 percent of those women were spared the consequences of axillary dissection,” he says.

Dr. Goldfarb notes that an important point about the outcomes analysis is that these women have been followed by their surgeons every three to four months for the first two years following their surgery, every six months for the next two years, and then annually. Additionally, they are seen on this same schedule by their medical oncologists and, for those women who underwent radiation therapy, there are regular visits with the radiation oncologists as well. Finally, the patients undergo breast-imaging follow-up at the breast center as well.

“So it should be understood that the results of their treatment are corroborated by the scrutiny of all these physicians, and the records are tallied through the hospital’s tumor registry,” he says. “Because a thorough analysis of the outcomes of diagnosis and treatment is crucial, Monmouth Medical Center offers a cancer registry that analyzes the breast center’s significant patient volume and is a good assessment of the quality of treatment. “

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