Correspondence

Reanalysis of a Trial Comparing Total Mastectomy with Lumpectomy

N Engl J Med 1996; 334:989April 11, 1996

Article

To the Editor:

It is useful to be reminded of the hypothesis that Fisher et al. were testing when they compared lumpectomy alone with lumpectomy plus radiation in the NSABP Protocol B-06 trial (Nov. 30 issue).1 Fisher et al. articulate two divergent hypotheses of tumor biology: “Halstedean” and “alternative.”2 The Halstedean hypothesis3 argues that breast cancer is an orderly disease, spreading in a contiguous fashion from the primary site through the lymphatic vessels to the lymph nodes and then to distant sites. Appropriate treatment would thus emphasize early and complete eradication of the primary tumor, draining lymphatic vessels and lymph nodes before metastases occur. The crucial point of the alternative hypothesis — the one Fisher et al. prefer — is that operable breast cancer is a systemic disease and that variations in local regional therapy are unlikely to affect survival substantially.2 This hypothesis is tested by comparing lumpectomy with lumpectomy plus radiation. The local recurrence rates in women with node-negative cancer were markedly different: 35 percent in those treated with lumpectomy alone as compared with 10 percent in those treated with lumpectomy plus radiation. Furthermore, the article states,

This suggests that the alternative hypothesis is rejected by these studies, although greater insight could be gained if the data could be examined. Since there is a 25 percent difference (35 percent vs. 10 percent) between the two groups, the largest difference one would expect in distant-disease–free survival would be 25 percent if this persistent local disease were the cause of the distant metastases. It would be important to compare the actual difference in distant metastases.

The continued use of lumpectomy alone as a treatment for breast cancer should no longer be an accepted treatment.

Samuel Hellman, M.D.
University of Chicago, Chicago, IL 60637-1470

3 References

1. 1

   Fisher B, Anderson S, Redmond CK, Wolmark N, Wickerham DL, Cronin WM. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456-1461
   Full Text | Web of Science | Medline

2. 2

   Fisher B. Laboratory and clinical research in breast cancer -- a personal adventure: the David A. Karnofsky Memorial Lecture. Cancer Res 1980;40:3863-3874
   Web of Science | Medline

3. 3

   Halsted WS. The results of radical operations for the cure of carcinoma of the breast. Ann Surg 1907;46:1-19
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Abram Recht. (1998) Local Control and Survival in Early Stage Breast Cancer. The Breast Journal 4:5, 372-378
   CrossRef

2. 2

   Skye Hongiun Cheng, James Jer-Min Jian, Kwan-Yee Chan, Stella Y. C. Tsai, Mei-Ching Liu, Chii-Ming Chen. (1998) The Benefit and Risk of Postmastectomy Radiation Therapy in Patients with High-Risk Breast Cancer. American Journal of Clinical Oncology 21:1, 12-17
   CrossRef