The Efficacy of Primary Surgery Compared to Post Chemotherapy Surgery for Patients with Locally Advanced Breast Cancer
Authors: Ibrahim Albalawi
Number of views: 342
Purpose: to compare primary surgery and surgery after neoadjuvant chemotherapy (NCT) in locally advanced breast cancer (LABC) patients for whom loco-regional& systemic treatment in the form of chemotherapy and radiotherapy were performed. Patients and methods: Between 2008 & 2011, 112 patients with LABC were treated at KAAH & OC-Jeddah-KSA. Of whom 42 were treated by NCT followed by surgery either mastectomy or conservative surgery, then adjuvant chemotherapy and radiotherapy. The rest patients (70) were treated by primary surgery (mastectomy or conservative resection) followed by adjuvant chemotherapy and radiotherapy. All patients received adjuvant antiestrogen. Patients were followed for a median duration of 33 months. Disease- free survival (DFS) and overall survival (OAS) were studied for all patients, compared between both groups and related to extent of surgery and menopausal status.
Results: median age was 46.5 years for all patients. 48 years, and 46 years for NCT and primary surgery groups respectively. Median DFS was 15 months for all patients, 16 & 15 months for NCT and primary surgery groups. Median OAS was 24 months for all patients, 22 & 24 months for NCT and primary surgery groups. Difference in DFS& OAS were highly significant in favor of postmenopausal patients (p = 0.05 for DFS & p = 0.03 for OAS) while in primary surgery group the differences between pre and postmenopausal patients in DFS & OAS were statistically insignificant (p = 0.4). NCT followed by surgery group patients showed significant improvement in DFS & OAS in patients performed conservative surgery while in primary surgery group the difference was insignificant. The results of neoadjuvant chemotherapy showed (14.3%) complete clinical remission (33.3%) showed more than 50% primary tumor regression, while the rest of patients (52.4%) showed less than 50% reduction of the primary tumor. The incidence of metastases was 56.5% for all patients, 49.4% for NCT group and 61.1% for primary surgery group. Freedom of disease was seen in 28.6% in NCT group and 37.1% for primary surgery group and local recurrence was noticed in 23.8% in NCT group Vs 2.9% in the primary surgery group.
Conclusion: Surgery post-neoadjuvant chemotherapy neither prolongs DFS nor OAS in comparison with primary surgery followed by adjuvant chemotherapy. However, it permits more conservative surgery to be performed in LABC patients, but many of these patients could not achieve complete pathological remission leading to increased incidence of local failure. Postmenopausal patients fared much better than premenopausal patients regarding DFS & OAS. Earlier surgical interference with modified radical mastectomy for those who showed minimal response to NCT (after 2 courses) is highly recommended. Alternatively, aggressive treatment with newer chemotherapeutic drugs or increasing dose intensity plus growth factor support may be warranted for younger patients to improve the outcome of conservative surgery.