Skip to main content

Advertisement

SpringerLink
Log in

Survival After Breast-Conserving Surgery Compared with that After Mastectomy in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Breast-conserving surgery (BCS) plus radiotherapy (BCS + RT) has been shown to improve survival compared with mastectomy in patients with early breast cancer; however, whether this superiority is maintained in breast cancer patients receiving neoadjuvant chemotherapy (NCT) is unclear. We evaluated and compared the survival outcomes after BCS + RT and mastectomy in Korean women with breast cancer treated with NCT.

Methods

We evaluated 1641 patients who received NCT before surgery (BCS or mastectomy). We performed propensity score matching to minimize potential bias due to factors other than the surgical method and compared the 5-year, disease-free survival (DFS), distant metastasis-free survival (DMFS), and overall survival (OS) rates before and after exact matching.

Results

Among the 1641 patients, 839 (51.1%) underwent BCS + RT and 802 (48.9%) underwent mastectomy. Patients who underwent mastectomy had larger tumors and more frequently had positive nodes. For BCS+RT and mastectomy, the unadjusted 5-year DFS, 5-year DMFS, and 5-year OS rates were 87.0% and 73.1%, 89.5% and 77.0%, and 91.8% and 81.0%, respectively (all p < 0.05 = 0.000). After PSM, 5-year DFS, 5-year DMFS, and 5-year OS rates for BCS + RT and mastectomy were 87.6% and 69.1%, 89.7% and 76.0%, and 89.1% and 75.7%, respectively (all p < 0.05). In both unadjusted and adjusted analyses accounting for various confounding factors, BCS + RT was significantly associated with improved DFS (p < 0.05), DMFS (p < 0.05), and OS (p < 0.05) rates compared with mastectomy.

Conclusions

BCS + RT does not impair DFS and OS in patients treated with NCT. Tumor biology and treatment response are significant prognostic indicators. Our results suggest that BCS + RT may be preferred in most breast cancer patients when both BCS and mastectomy are suitable.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Veronesi U, Cascinelli N, Mariani L, Greco M, Saccozzi R, Luini A, et al. Twenty-year follow-up of a randomized study comparing breast-conserving surgery with radical mastectomy for early breast cancer. N Engl J Med. 2002;347(16):1227–32.

    Article  PubMed  Google Scholar 

  2. Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med. 2002;347(16):1233–41.

    Article  PubMed  Google Scholar 

  3. Litière S, Werutsky G, Fentiman IS, Rutgers E, Christiaens MR, Van Limbergen E, et al. Breast conserving therapy versus mastectomy for stage I–II breast cancer: 20 year follow-up of the EORTC 10801 phase 3 randomised trial. Lancet Oncol. 2012;13(4):412–9.

    Article  PubMed  Google Scholar 

  4. Agarwal S, Pappas L, Neumayer L, Kokeny K, Agarwal J. Effect of breast conservation therapy vs mastectomy on disease-specific survival for early-stage breast cancer. JAMA Surgery. 2014;149(3):267–74.

    Article  PubMed  Google Scholar 

  5. Chen K, Liu J, Zhu L, Fengxi S, Song E, Jacobs LK. Comparative effectiveness study of breast-conserving surgery and mastectomy in the general population: a NCDB analysis. Oncotarget. 2015;6(37):40127.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Fisher S, Gao H, Yasui Y, Dabbs K, Winget M. Survival in stage I-III breast cancer patients by surgical treatment in a publicly funded health care system. Ann Oncol. 2015;26(6):1161–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Hartmann-Johnsen OJ, Kåresen R, Schlichting E, Nygård JF. Survival is better after breast conserving therapy than mastectomy for early stage breast cancer: a registry-based follow-up study of Norwegian women primary operated between 1998 and 2008. Ann Surg Oncol. 2015;22(12):3836–45.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Shelley Hwang E, Lichtensztajn DY, Gomez SL, Fowble B, Clarke CA. Survival after lumpectomy and mastectomy for early stage invasive breast cancer: the effect of age and hormone receptor status. Cancer. 2013;119(7):1402–11.

    Article  PubMed  Google Scholar 

  9. Onitilo AA, Engel JM, Stankowski RV, Doi SAR. Survival comparisons for breast conserving surgery and mastectomy revisited: community experience and the role of radiation therapy. Clin Med Res. 2015;13(2):65–73.

    Article  PubMed  PubMed Central  Google Scholar 

  10. van Maaren MC, de Munck L, de Bock GH, Jobsen JJ, van Dalen T, Linn SC, et al. 10 year survival after breast-conserving surgery plus radiotherapy compared with mastectomy in early breast cancer in the Netherlands: a population-based study. Lancet Oncol. 2016;17(8):1158–70.

    Article  PubMed  Google Scholar 

  11. Lagendijk Mi, van Maaren MC, Saadatmand S, Strobbe LJA, Poortmans PMP, Koppert LB, et al. Breast conserving therapy and mastectomy revisited: breast cancer-specific survival and the influence of prognostic factors in 129,692 patients: BCT and mastectomy revisited. Int J Cancer. 2018;142(1):165–75.

    Article  CAS  PubMed  Google Scholar 

  12. Fisher B, Brown A, Mamounas E, Wieand S, Robidoux A, Margolese RG, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997;15(7):2483–93.

    Article  CAS  PubMed  Google Scholar 

  13. van der Hage JA, van de Velde CJH, Julien JP, Tubiana-Hulin M, Vandervelden C, Duchateau L. Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer trial 10902. J Clin Oncol. 2001;19(22):4224–37.

    Article  PubMed  Google Scholar 

  14. Caudle AS, Bedrosian I, Milton DR, DeSnyder SM, Kuerer HM, Hunt KK, Mittendorf EA. Use of sentinel lymph node dissection after neoadjuvant chemotherapy in patients with node-positive breast cancer at diagnosis: practice patterns of American society of breast surgeons members. Ann Surg Oncol. 2017;10:2925–34.

    Article  Google Scholar 

  15. Petruolo O, Sevilimedu V, Montagna G, Le T, Morrow M, Barrio AV, et al. How often does modern neoadjuvant chemotherapy downstage patients to breast-conserving surgery? Ann Surg Oncol. 2021;28:287–94.

    Article  PubMed  Google Scholar 

  16. Meisamy S, Bolan PJ, Baker EH, Bliss RL, Gulbahce E, Everson LI, et al. Neoadjuvant chemotherapy of locally advanced breast cancer: predicting response with in vivo 1H MR spectroscopy—a pilot study at 4 T. Radiology. 2004;233(2):424–31.

    Article  PubMed  Google Scholar 

  17. Cerussi A, Hsiang D, Shah N, Mehta R, Durkin A, Butler J, et al. Predicting response to breast cancer neoadjuvant chemotherapy using diffuse optical spectroscopy. Proc Natl Acad Sci. 2007;104(10):4014–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Sharma U, Karikanni KA, Danishad VS, Jagannathan NR. Longitudinal study of the assessment by MRI and diffusion-weighted imaging of tumor response in patients with locally advanced breast cancer undergoing neoadjuvant chemotherapy. NMR Biomed. 2009;22(1):104–13.

    Article  PubMed  Google Scholar 

  19. Manton DJ, Chaturvedi A, Hubbard A, Lind MJ, Lowry M, Maraveyas A, et al. Neoadjuvant chemotherapy in breast cancer: early response prediction with quantitative MR imaging and spectroscopy. Br J Cancer. 2006;94(3):427.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Rajan R, Poniecka A, Smith TL, Yang Y, Frye D, Pusztai L, et al. Change in tumor cellularity of breast carcinoma after neoadjuvant chemotherapy as a variable in the pathologic assessment of response. Cancer. 2004;100(7):1365–73.

    Article  PubMed  Google Scholar 

  21. Baek HM, Chen JH, Nie K, Yu HJ, Bahri S, Mehta RS, et al. Predicting pathologic response to neoadjuvant chemotherapy in breast cancer by using MR imaging and quantitative 1H MR spectroscopy. Radiology. 2009;251(3):653–62.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Asselain B, Barlow W, Bartlett J, Bergh J, Bergsten-Nordström E, Bliss J, et al. Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials. Lancet Oncol. 2018;19(1):27–39.

    Article  Google Scholar 

  23. Rubio IT, Wyld L, Cardoso F, Curigliano G, Kovacs T, Poortmans P, Cortes J. Perspectives on preoperative systemic treatment and breast conservative surgery: One step forward or two steps back? The Breast. 2018;41:133–5. https://doi.org/10.1016/j.breast.2018.07.008.

    Article  CAS  PubMed  Google Scholar 

  24. Allred DC, Harvey JM, Berardo M, Clark GM. Prognostic and predictive factors in breast cancer by immunohistochemical analysis. Mod Pathol. 1998;11(2):155–68.

    CAS  PubMed  Google Scholar 

  25. Wolff AC, Elizabeth M, Hammond H, Hicks DG, Dowsett M, McShane LM, et al. Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American society of clinical oncology/college of american pathologists clinical practice guideline update. Arch Pathol Lab Med. 2014;138(2):241–56.

    Article  PubMed  Google Scholar 

  26. Edge SB, Compton CC. The American joint committee on cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17(6):1471–4.

    Article  PubMed  Google Scholar 

  27. Gradishar WJ, Moran MS, Abraham J, Aft R, Agnese D, Allison KH, et al. NCCN Guidelines® insights: breast cancer, version 4.2021: featured updates to the NCCN guidelines. J Natl Compr Cancer Netw. 2021;19(5):484–93.

    Article  Google Scholar 

  28. McGale P, Correa C, Cutter D, Duane F, Ewertz M, Gray R, et al. Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet. 2014;383(9935):2127–35.

    Article  CAS  PubMed  Google Scholar 

  29. Gentilini OD, Cardoso MJ, Poortmans P. Less is more. Breast conservation might be even better than mastectomy in early breast cancer patients. Breast. 2017;35:32–3.

    Article  PubMed  Google Scholar 

  30. Loibl S, von Minckwitz G, Raab G, Blohmer JU, Costa SD, Gerber B, et al. Surgical procedures after neoadjuvant chemotherapy in operable breast cancer: results of the GEPARDUO trial. Ann Surg Oncol. 2006;13(11):1434–42.

    Article  PubMed  Google Scholar 

  31. Bélanger J, Soucy G, Sidéris L, Leblanc G, Drolet P, Mitchell A, et al. Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count. J Am Coll Surg. 2008;206(4):704–8.

    Article  PubMed  Google Scholar 

  32. Kuerer HM, Eva Singletary S, Buzdar AU, Ames FC, Valero V, Buchholz TA, et al. Surgical conservation planning after neoadjuvant chemotherapy for stage II and operable stage III breast carcinoma. Am J Surg. 2001;182(6):601–8.

    Article  CAS  PubMed  Google Scholar 

  33. Vlastos G, Mirza NQ, Lenert JT, Hunt KK, Ames FC, Feig BW, et al. The feasibility of minimally invasive surgery for stage IIA, IIB, and IIIA breast carcinoma patients after tumor downstaging with induction chemotherapy. Cancer. 2000;88(6):1417–24.

    Article  CAS  PubMed  Google Scholar 

  34. Veronesi U, Bonadonna G, Zurrida S, Galimberti V, Greco M, Brambilla C, et al. Conservation surgery after primary chemotherapy in large carcinomas of the breast. Ann Surg. 1995;222(5):612.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Fisher B, Bryant J, Wolmark N, Mamounas E, Brown A, Fisher ER, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol. 1998;16(8):2672–85.

    Article  CAS  PubMed  Google Scholar 

  36. Makris A, Powles TJ, Ashley SE, Chang J, Hickish T, Tidy VA, et al. A reduction in the requirements for mastectomy in a randomized trial of neoadjuvant chemoendocrine therapy in primary breast cancer. Ann Oncol. 1998;9(11):1179–84.

    Article  CAS  PubMed  Google Scholar 

  37. Boughey JC, Peintinger F, Meric-Bernstam F, Perry AC, Hunt KK, Babiera GV, et al. Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg. 2006;244(3):464.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Simons JM, Jacobs JG, Roijers JP, Beek MA, Boonman-de LJM, Winter AM, et al. Disease-free and overall survival after neoadjuvant chemotherapy in breast cancer: breast-conserving surgery compared to mastectomy in a large single-centre cohort study. Breast Cancer Res Treat. 2021;185(2):441–51.

    Article  PubMed  Google Scholar 

  39. Arlow RL, Paddock LE, Niu X, Kirstein L, Haffty BG, Goyal S, et al. Breast-conservation therapy after neoadjuvant chemotherapy does not compromise 10-year breast cancer–specific mortality. Amer J Clin Oncol. 2018;41(12):1246–51.

    Article  Google Scholar 

  40. Cho JH, Park JM, Park HS, Park S, Kim SI, Park BW. Oncologic safety of breast-conserving surgery compared to mastectomy in patients receiving neoadjuvant chemotherapy for locally advanced breast cancer: BCS After Neoadjuvant Chemotherapy. J Surg Oncol. 2013;108(8):531–6. https://doi.org/10.1002/jso.23439.

    Article  PubMed  Google Scholar 

  41. Wolmark N, Wang J, Mamounas E, Bryant J, Fisher B. Preoperative chemotherapy in patients with operable breast cancer: nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18. JNCI Monographs. 2001;2001(30):96–102.

    Article  Google Scholar 

  42. Rouzier R, Extra JM, Carton M, Falcou MC, Vincent-Salomon A, Fourquet A, et al. Primary chemotherapy for operable breast cancer: incidence and prognostic significance of ipsilateral breast tumor recurrence after breast-conserving surgery. J Clin Oncol. 2001;19(18):3828–35.

    Article  CAS  PubMed  Google Scholar 

  43. Chen AM, Meric-Bernstam F, Hunt KK, Thames HD, Jane Oswald M, Outlaw ED, et al. Breast conservation after neoadjuvant chemotherapy: the MD Anderson cancer center experience. J Clin Oncol. 2004;22(12):2303–12.

    Article  PubMed  Google Scholar 

  44. Mieog J, Van der Hage J, Van De Velde C. Neoadjuvant chemotherapy for operable breast cancer. J Br Surg. 2007;94(10):1189–200.

    Article  CAS  Google Scholar 

  45. Mittendorf EA, Bucholz TA, Tucker SL, Meric-Bernstam F, Kuerer HM, Gonzalez-Angulo AM, et al. Impact of chemotherapy sequencing on local-regional failure risk in breast cancer patients undergoing breast-conserving therapy. Ann Surg. 2013;257(2):173.

    Article  PubMed  Google Scholar 

  46. Shin HC, Han W, Moon HG, Im SA, Moon WK, Park IA, et al. Breast-conserving surgery after tumor downstaging by neoadjuvant chemotherapy is oncologically safe for stage III breast cancer patients. Ann Surg Oncol. 2013;20(8):2582–9.

    Article  PubMed  Google Scholar 

  47. Haque W, Verma V, Sandra Hatch V, Suzanne Klimberg E, Butler B, Teh BS. Response rates and pathologic complete response by breast cancer molecular subtype following neoadjuvant chemotherapy. Breast Cancer Res Treat. 2018;170(3):559–67.

    Article  CAS  PubMed  Google Scholar 

  48. Houssami N, Macaskill P, von Minckwitz G, Marinovich ML, Mamounas E. Meta-analysis of the association of breast cancer subtype and pathologic complete response to neoadjuvant chemotherapy. Eur J Cancer. 2012;48(18):3342–54.

    Article  CAS  PubMed  Google Scholar 

  49. Cortazar P, Zhang L, Untch M, Mehta K, Costantino JP, Wolmark N, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014;384(9938):164–72. https://doi.org/10.1016/S0140-6736(13)62422-8.

    Article  PubMed  Google Scholar 

  50. von Minckwitz G, Untch M, Blohmer JU, Costa SD, Eidtmann H, Fasching PA, et al. Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol. 2012;30(15):1796–804.

    Article  Google Scholar 

  51. Mougalian SS, Hernandez M, Lei X, Lynch S, Kuerer HM, Symmans WF, et al. Ten-year outcomes of patients with breast cancer with cytologically confirmed axillary lymph node metastases and pathologic complete response after primary systemic chemotherapy. JAMA Oncol. 2016;2(4):508–16.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Kuerer HM, Rauch GM, Krishnamurthy S, Adrada BE, Caudle AS, DeSnyder SM. A clinical feasibility trial for identification of exceptional responders in whom breast cancer surgery can be eliminated following neoadjuvant systemic therapy. Ann Surg. 2018;267(5):946–51.

    Article  PubMed  Google Scholar 

  53. Kang SY, Kim YS, Kim Z, Kim HY, Kim HJ, Park S, Bae SY, et al. Breast cancer statistics in Korea in 2017: data from a breast cancer registry. J Breast Cancer. 2020;23(2):115.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Heer E, Harper A, Escandor N, Sung H, McCormack V, Fidler-Benaoudia MM. Global burden and trends in premenopausal and postmenopausal breast cancer: a population-based study. Lancet Global Health. 2020;8(8):e1027–37.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This study was supported by the grant “Elimination of Cancer Project Fund” from Asan Cancer Institute of Asan Medical Center, Seoul (2017-1341). This article was supported by the Korean Breast Cancer Society.

Author information

Authors and Affiliations

  1. Department of Surgery, Ewha Womans University College of Medicine, Ewha Womans University Mokdong Hospital, Seoul, South Korea

    Sungchan Gwark MD, PhD & Sei Hyun Ahn MD, PhD

  2. Department of Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea

    Hwa Jung Kim MD, PhD

  3. Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

    Jisun Kim MD, PhD, Il Yong Chung MD, PhD, Hee Jeong Kim MD, PhD, Beom Seok Ko MD, PhD, Jong Won Lee MD, PhD, Byung Ho Son MD, PhD & Sae Byul Lee MD, PhD

Authors
  1. Sungchan Gwark MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hwa Jung Kim MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jisun Kim MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Il Yong Chung MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Hee Jeong Kim MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Beom Seok Ko MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jong Won Lee MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Byung Ho Son MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Sei Hyun Ahn MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Sae Byul Lee MD, PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sae Byul Lee MD, PhD.

Ethics declarations

Disclosure

The authors have no conflicts of interest to declare.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gwark, S., Kim, H.J., Kim, J. et al. Survival After Breast-Conserving Surgery Compared with that After Mastectomy in Breast Cancer Patients Receiving Neoadjuvant Chemotherapy. Ann Surg Oncol 30, 2845–2853 (2023). https://doi.org/10.1245/s10434-022-12993-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1245/s10434-022-12993-0

Search

Navigation