Who Should Not Undergo Breast Conservation?

Optimal local control is one of the three main aims of breast cancer treatment (next to optimal regional control and reducing the risk of distant relapses by adequate systemic treatments). To this end, many women desire breast conservation provided local control is comparable to that of ablative procedures, the cosmetic outcome is good and side effects of treatment are limited. To achieve this delicate balance the following should be part of the information to the patient with an operable breast cancer: Patients should have an open discussion with there care providers to enable a shared decision: this will lead to less anxiety and stress with the best satisfaction and recovery. The possibility of breast conservation should always be explored. Even with equal local control and survival outlook, quite a minority (about 20%) of patients opt for ablative procedures (with or without breast reconstruction). Higher risk of local relapse (i.e. persistent cancer growth in the breast) is associated with higher risk of distant disease and subsequent risk of dying of breast cancer. Rough estimates indicate that for every four local relapses one patient may die from breast cancer due to persistent disease. This estimate may vary substantially with the type of cancers (see dr. Morrow), age at diagnosis, application and duration of systemic treatments. To limit the negative effect on overall survival through local relapses, it is generally accepted that for early breast cancer local relapse rates should be within the limit of 1% per year, or within 10% at 10 years. Current population based overviews and hospital based studies show that the risk of local relapse after breast conservations are very well below this limit, being around 2-3% at 5 years. There is no absolute risk threshold of local relapse incidence above which breast conservation is absolutely contra indicated: this will remain an individual decision. Oncoplastic procedures should widely be available to adjust to the width of the local excision and to improve cosmetic outcome. In larger cancers, the option of neo-adjuvant chemotherapy must be considered: about one-third of "mastectomy candidates" can be conversed to an oncologically safe breast conservation. The most important independent risk factors for a breast relapse are: more than focally incomplete margins (roughly 2 times increased risk), young age (<35 years, 2 times increased risk) no radiotherapy (2-4 times increased risk). These risk factors again may also be influenced by the biological type of breast cancer. Combination of risk factors should be added: e.g. young women (<35 years) who had breast conservation for DCIS without radiotherapy may face 15 years breast relapse rate of over 40%. In aggregate, in the following clinical situations the increased risk of breast relapse should be extensively discussed with the patient and breast conservation should be executed with caution: Very young women (<35 years) Extensive DCIS (heralded by extensive microcalcifications) mounting up to one quarter of the breast, particularly in women under 40 years of age. More than focally incomplete resection of an invasive or in situ cancer. Radiotherapy cannot be given. The following factors should, as it stands, not be considered as a contra indication for breast conservation:multi-focal breast cancer, multi-centric breast cancer, the location of the cancer in the breast (including retro areola location), vascular invasion and lobular histology. All with the provision that by the breast conserving surgery complete margins a good cosmetic outcome should be achieved.