Surgical Procedures For Breast Cancer - Mastectomy and Breast Conserving Therapy

8/25/2015
SurgicalproceduresforbreastcancerMastectomyandbreastconservingtherapy
OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate
Patientinformation:Surgicalproceduresforbreastcancer
Mastectomyandbreastconservingtherapy(Beyondthe
Basics)
Author
MichaelSSabel,MD
SectionEditor
AneesBChagpar,MD,MSc,
MA,MPH,MBA,FACS,
FRCS(C)
DeputyEditor
WenliangChen,MD,PhD
BREASTCANCEROVERVIEW
BreastcanceristhemostcommonfemalecancerintheUnitedStates.Findingandtreatingbreastcancerin
theearlystagesallowsmanywomentobecured.
Thisarticlewillfocusonthesurgicaltreatmentofbreastcancer.Anintroductiontobreastcancerandan
overviewoftreatmentforbreastcancerisalsoavailable.(See"Patientinformation:Breastcancerguideto
diagnosisandtreatment(BeyondtheBasics)".)
BREASTCANCERSTAGING
Inadditiontoremovingthecancerfromthebreastandlymphnodes,surgeryalsoprovidesimportant
informationaboutthe"stage"ofthecancer.Thestageofthebreastcancer(TNM)isbaseduponthesizeof
thetumorinthebreast(T),statusoflymphnodes(N),andmetastaticspreadtodistantsites(M).
Stagingisdiscussedindetailinaseparatearticle.(See"Patientinformation:Breastcancerguidetodiagnosis
andtreatment(BeyondtheBasics)".)
FACTORSAFFECTINGSURGICALTREATMENT
Severalfactorsmustbeconsideredwhenchoosingthebestsurgicaltreatmentforyourbreastcancer.You
shoulddiscussthesefactorswithyourphysicianasyoudecidewhichtreatmentisbestforyou.
MicroscopicfindingsThesurgeonmustdetermineifabreastcancerisinvasiveornoninvasive(insitu).
(See"Patientinformation:Breastcancerguidetodiagnosisandtreatment(BeyondtheBasics)",sectionon
'Typesofbreastcancer'.)
InvasivebreastcancerInvasivebreastcancersusuallyrequiresurgicaltreatment(mastectomyor
breastconservingtherapy)aswellastreatmentaftersurgery(calledadjuvanttreatment).Adjuvanttreatment
canincluderadiationaswellassystemictreatmentsuchaschemotherapyorendocrinetherapy.
Noninvasive(insitu)breastcancerNoninvasiveorinsitubreastcancerisdividedintotwotypes:
lobularcarcinomainsitu(LCIS)andductalcarcinomainsitu(DCIS).
LCISWomenwithLCIShaveanincreasedriskofdevelopingbreastcancerinthefuture.However,LCIS
doesnotrequiretreatment.ManagementofLCISisdiscussedseparately.(See"Atypiaandlobularcarcinoma
insitu:Highrisklesionsofthebreast".)
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DCISWomenwithDCISrequiresurgicaltreatment(mastectomyorbreastconservingtherapy)aswellas
treatmentaftersurgery(calledadjuvanttreatment).Adjuvanttreatmentcanincluderadiationaswellas
systemictreatmentsuchasendocrinetherapy.Chemotherapyisusuallynotnecessary.(See"Ductal
carcinomainsitu:Treatmentandprognosis"and"Microinvasivebreastcarcinoma".)
SizeofthebreasttumorLargertumorsaremorelikelytorecurandusuallyrequiremoreaggressive
treatment.Largetumors(5cmoraboutthesizeofanegg)mayrequirechemotherapybeforesurgery,whichis
calledneoadjuvantchemotherapy.Thisisgiveninordertoshrinkthetumorandallowforlumpectomy.(See
"Neoadjuvanttherapyforbreastcancer:Rationale,pretreatmentevaluation,andtherapeuticoptions".)
Tumorsthatinvadetheskinandinflammatorybreastcancersalsorequirechemotherapyandmastectomyis
usuallyrecommendedforthesemoreadvancedcancers.Thisisdiscussedinaseparatearticle.(See"Patient
information:Locallyadvancedandinflammatorybreastcancer(BeyondtheBasics)".)
SpreadtothelymphnodesLymphnodes(orglands)areusuallythefirstplaceforbreastcancertospread.
Ifabreastcancerhasspreadtolymphnodes,itiscallednodepositiveacancerthathasnotspreadtothe
lymphnodesiscallednodenegative.Ifabreastcancerhasspreadtothelymphnodes,itistwiceaslikelyto
havealsospreadelsewhere,andtherefore,torecur.
However,evenwhencancerhasspreadtothelymphnodes,thereisstillachanceithasnotspreadanywhere
elseinthebody.Thegoalofsurgeryistoremovecancerfromboththebreastandthelymphnodes.(See
'Managementofaxillarylymphnodes'below.)
SURGICALTREATMENT
Surgicalremovalofthetumorisusuallythefirststepintreatingearlystagebreastcancer.Ifthebreasttumor
islargeormoreadvanced,treatmentwithchemotherapy,trastuzumab,orsometimesantiestrogentherapy
mayberecommendedbeforesurgery.(See"Patientinformation:Locallyadvancedandinflammatorybreast
cancer(BeyondtheBasics)",sectionon'Treatmentoflocallyadvancedbreastcancer'.)
Therearetwooptionsforbreastsurgery:
Mastectomyinvolvesremovingtheentirebreast.(See'Mastectomy'below.)
Breastconservingsurgeryremovesjustthecancerousareaandasmallamountofsurroundingnormal
tissue(alsocalledlumpectomy).Breastconservingsurgeryplusradiationtherapyisreferredtoasbreast
conservingtherapy,orBCT.(See'Breastconservingtherapy(BCT)'below.)
Incentersthatspecializeinbreastcancertreatment,approximately75percentofwomenwithearlystage
breastcancerarecandidatesforBCT.In25to50percentofwomen,therearemedical,cosmeticand/orsocial
andemotionalreasonsforhavingamastectomyratherthanBCT.Survivaloutcomesarethesamewhether
BCTormastectomyisperformed.
MASTECTOMY
Mastectomymaybenecessarybecauseofthelocationofyourtumor,thesizeorshapeofyourbreast,
findingsonyourimagingexamination(mammogramorMRI),whetherradiationmaybeused,oritmaybeyour
preference.(See"Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement".)
SimplemastectomyAtotalorsimplemastectomyinvolvesremovingtheentirebreastwithoutremoving
theaxillarylymphnodes.Atechniquecalledsentinellymphnodebiopsyisperformedtobesurethatthe
cancerhasnotspreadtothelymphnodes.
SkinsparingmastectomyInaskinsparingmastectomy,thenippleandareolaareusuallyremovedbutthe
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restoftheskinoverthebreastispreserved.Thisisdoneinconjunctionwithimmediatereconstructionwitha
plasticsurgeon.
NipplesparingmastectomyandareolasparingmastectomyBecausethereisbreasttissueextendingto
thenippleareolarcomplex(NAC),standardmastectomies(bothsimpleandskinsparing)usuallyinvolve
removingtheNAC.However,forcertainsubsetsofpatients,itmaybesafetopreserveeithertheentireNAC
(thenipplesparingmastectomy,NSM)orremovethenipplewiththebreasttissuebutpreservetheareola
(areolasparingmastectomy,ASM).Aswiththeskinsparingmastectomy,thesearedoneinconjunctionwith
immediatereconstructionwithaplasticsurgeon.
ModifiedradicalmastectomyDuringamodifiedradicalmastectomy(MRM),thebreasttissueandthe
lymphnodesinthearmpit(theaxillarylymphnodes)areremoved.Anaxillarynodedissectionisnecessary
onlyifthecancerhasspreadtothelymphnodes.(See'Managementofaxillarylymphnodes'below.)
BreastreconstructionReconstructionofthebreastisanimportantoptionforwomenwhoundergo
mastectomy.Youmaychoosetohavebreastreconstructionimmediatelyafterthemastectomyoratalater
time.Thenipplesmayalsobereconstructedtoallowthebreasttoappearmorenatural.Thereareseveral
optionsforreconstruction,andallwomenplanningtoundergomastectomyshouldseeaplasticor
reconstructivesurgeontodiscusstheseoptionsbeforehavingbreastsurgery.(See"Breastreconstruction:
Preoperativeassessment".)
ComplicationsofmastectomyMastectomyisgenerallyasafesurgery,althoughcomplicationscanoccur,
includingbleeding,collectionoffluid,woundinfection,andarmproblems.(See"Patientinformation:
Lymphedemaaftercancersurgery(BeyondtheBasics)".)
RadiationtherapyaftermastectomyRadiationtherapyissometimesrecommendedafteramastectomyto
decreasethechanceofarecurrence,especiallyinwomenwhohavelargetumors(5cminsizeorlarger),have
tumorsclosetothechestwall,orwhohavefourormorepositivelymphnodes[1].Thebenefitofradiationafter
mastectomyforwomenwithsmallertumorsorfewerinvolvedlymphnodesiscontroversial.
Moreinformationaboutradiationtherapyisavailablebelow.(See'Radiationtherapy'below.)
BREASTCONSERVINGTHERAPY(BCT)
Breastconservingtherapyreferstosurgicalremovalofthetumorandasmallportionofnormalsurrounding
breasttissue.BCTisalmostalwaysfollowedbyradiationtherapytotheremainingbreasttissue.Breast
conservingsurgeryisalsocalledapartialmastectomy,andlessaccurately,alumpectomy.Apartial
mastectomyisthemostcommonlyperformedBCTprocedureintheUnitedStatesandCanada.
Aquadrantectomy,whichismoreoftenusedoutsideofNorthAmerica,referstoremovalofthetumorand
aboutonefourthofthebreasttissueonthatside.Theremainderofthisarticlewillusethewordlumpectomy,
althoughtheinformationalsoappliestowomenwhohavehadaquadrantectomy.(See"Breastconserving
therapy".)
Radiationtherapy
InvasivebreastcancerRadiationtherapy(RT)referstotheexposureofatumortohighenergyxraysin
ordertosloworstopitsgrowth.Exposuretoxraysdamagescells.Unlikenormalcells,cancercellscannot
repairthedamagecausedbyexposuretoxraysoverseveraldays.Thispreventsthecancercellsfrom
growingfurtherandcausesthemtoeventuallydie.
RTforbreastcancerismostlygivenasexternalbeamRT,meaningthattheradiationbeamisgeneratedbya
machinethatisoutsidethepatient.Exposuretothebeamtypicallytakesonlyafewseconds(similartohaving
anxray).Ingeneral,RTisgivendaily,fivedaysperweek,forapproximatelyfivetosixweeks.Somepatients
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maybecandidatesforanacceleratedcourseofRT,whichisonlygiventothepartofthebreastwherethe
cancerwasremoved.Thisiscalledacceleratedpartialbreastirradiation.
Radiationisgenerallyrecommendedformostwomenwhohavehadbreastconservingsurgeryforinvasive
breastcancer,evenifthetumorisverysmall.Thegoalofthistreatmentistokillanyremainingcancercells.
Somewomen,particularlythosewithmanyothermedicalconditions,maybesafelytreatedwithoutradiation.
InsitubreastcancerMostwomenwithductalcarcinomainsitu(DCIS)willbeadvisedtohave
radiationtherapyafterbreastconservingsurgery.ThiswilldependonthesizeandgradeoftheDCIS,your
age,andwhethertheDCISishormonereceptorpositive.(See"Breastductalcarcinomainsitu:Epidemiology,
clinicalmanifestations,anddiagnosis"and"Ductalcarcinomainsitu:Treatmentandprognosis"and
"Microinvasivebreastcarcinoma".)
CosmeticoutcomesWithmodernsurgicaltechniques,cosmeticresultsaregoodtoexcellentinmost
womenafterbreastconservingtherapy(ie,thetreatedanduntreatedbreastarealmostidenticalorthereare
onlyslightdifferences).TheeffectsofBCTontheappearanceofthebreasttakeaboutthreeyearstostabilize.
Factorssuchasweightgainandthenormalagerelatedsaggingofbreasttissuealsoaffecttheshapeandsize
ofthebreasts.
ComplicationsfollowingBCTFollowingbreastconservingsurgeryorradiation,complicationscan
sometimesoccur,includingbleeding,pain,infectionorcollectionoffluid.
MASTECTOMYVERSUSBREASTCONSERVINGTHERAPY
Studiesshowthatwomenwithlocalizedbreastcancerareequallylikelytosurvivetheircancerwhetherthey
aretreatedwithBCToramastectomy[1,2].
FactorstoconsiderAlthoughcanceroutcomesaresimilar,thereareseveralfactorsthatyoushould
considerwhentryingtodecidebetweenBCTandmastectomy.
TumorsizeSomewomenwhohavealargetumorandsmallbreastsareadvisedtoundergo
mastectomyratherthanBCT.However,chemotherapymaybegivenbeforesurgerytoshrinkthetumor
thismayallowthewomantohavebreastconservingsurgery,ifshedesiresit.
ExtensiveDCISExtensiveductalcarcinomainsitu(DCIS),averyearlycancer,doesnotrespondwell
tochemotherapyandthereforemaynecessitateamastectomyinordertomakesurethatallthedisease
isremoved.
TumormarginsAfterlumpectomy,itisimportanttohaveamarginofnormalbreasttissuearoundthe
tumor.Ifcancercellsarefoundatorneartheedgesofthetissueremoved,additionalsurgerymaybe
necessary.Ifalargeamountoftissuehasbeenremovedandthemarginsarestillinvolved,mastectomy
mayberecommended.
TumorlocationTumorsthatareinthecenterofthebreastorinvolvethenippleortheskin,maybe
treatedwithamastectomyorbreastconservingsurgery,dependingupontheexpectedcosmeticresults.
NeedforradiationBCTinvolvesbothlumpectomyandradiation.Inaddition,whileradiationdoesallow
forpreservationofthebreast,therearebothimmediateandlongtermsideeffects.(See"Radiation
therapytechniquesfornewlydiagnosed,nonmetastaticbreastcancer".)
RiskreductionSomepatientswillopttohaveamastectomy(oftenonbothsides)toreducetheriskof
futurebreastcancers.Thisisparticularlythecaseinwomenwhocarryabreastcancergenemutationor
thosewithsignificantriskfactors(eg,lobularcarcinomainsituorasignificantfamilyhistory)
IndividualneedsandpreferencesYoushoulddiscussyourpreferencesandconcernsabout
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preservingyourbreastwithyourdoctor.
RiskofasecondbreastcancerSomewomenmaybecandidatesforBCTbutmaybeatahighriskof
developinganotherbreastcancer.Theseincludeveryyoungwomenandwomenwithaknownbreast
cancergenemutation.Thesewomenmayconsiderbilateralmastectomytonotonlytreattheknown
cancer,butpreventasecondcancerinthefuture.Womenwithaverystrongfamilyhistoryofbreast
cancer,suchasfamilymembersineveryknowngeneration(mother,grandmother,greatgrandmother),
arestillcandidatesforBCT,butmaywishtoundergobilateralmastectomies.
ReasonstoavoidBCTCertainfactorsclearlyfavormastectomyoverBCT.Theseinclude:
MultipletumorsHavingtwoormoreseparatetumorsindifferentareas(quadrants)ofthebreast.Some
patientshavemorethanonecancerinthebreastanditmaynotbepossibletoremoveallofthetumors
andstillsavethebreast.
ExtensivetumorIftumorisspreadthroughoutthebreasttissue,itwillnotbepossibletoremovethe
entiretumorwithoutamastectomy.
ContraindicationforradiationSomewomenarenotcandidatesforradiation,suchaswomenwhoare
pregnant,havealreadyhadradiationtothearea,orwithconditionsthatmakeradiationdangerous,such
aslupusskindisease.
FactorsthatdonotaffectyourdecisionSeveralfactorsdonotplayaroleinthechoicebetweenBCT
andmastectomy:
Thespreadofcancercellstolymphnodesintheaxilla
Achancethatbreastcancercellswillmetastasizeorspreadtootherlocationsinyourbody
MANAGEMENTOFAXILLARYLYMPHNODES
Mostwomenwithinvasivecancerwillhaveanoperationtocheckforcancercellsintheaxillarylymphnodes.
Womenwithductalcarcinomainsitu(DCIS)haveaverysmallchanceofhavingcancercellsspreadingtothe
axillarylymphnodes.Ingeneral,SLNbiopsyisnotrecommendedforwomenwithDCISunlessamastectomy
isbeingperformed.Inthatcase,SLNisdonesince,ifinvasivecancerisfoundinthemastectomyspecimen,
thesurgeoncannotgobackanddoaSLNprocedureafteramastectomy.
AxillarylymphnodedissectionThisprocedureinvolvesremovingmostofthelymphnodesintheaxilla
(armpit)toexaminethemforcancercellsandtohelppreventthespreadofthecancertodistantsites(suchas
thelung).Thisoperationwascommonlyperformedforwomenwithinvasivebreastcancerinthepastandis
associatedwithcomplicationssuchaspainandarmswelling(lymphedema).Anaxillarylymphnodedissection
isnowusuallyperformedonlyforpatientswhenlarge,cancerouslymphnodescanbefeltintheaxillaorwhen
thesentinellymphnodecontainsalargeburdenofcancercells.(See'Sentinellymphnodedefinition'below
and'Sentinellymphnodeexcision'below.)
SentinellymphnodedefinitionThesentinellymphnodeisthefirstlymphnodethatreceiveslymphatic
drainagefromthebreast.Thesentinelnodeforpatientswithbreastcancerisusuallylocatedintheaxilla,but
insomepatientsmaybenearthesternum(breastbone)betweentheribs(intercostallymphnodes).In
addition,theremaybemorethanonesentinellymphnode.Mostpatientsdonothavecancerintheirsentinel
lymphnodes.
SentinellymphnodeexcisionAsentinellymphnodeexcisionisperformedtosparepatientsanaxillary
lymphnodedissectionwhenpossible.Itisbaseduponthefindingthatifthesentinelnodedoesnotcontain
cancercells,thelikelihoodthatotherlymphnodesintheaxillacontaincancercellsisverysmall[1].
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Toidentifythesentinellymphnode,thesurgeoninjectsbluedyeoraradioactivematerial,oracombinationof
bothintothebreast.Thedyeorradioactivematerialentersthelymphaticchannelsandflowstothesentinel
lymphnode,whichhelpsthesurgeonidentifyandremovetheappropriatelymphnodes.Thesentinelnodesare
examinedunderthemicroscopebyapathologist.
Ifnocancercellsareidentifiedinthesentinelnode(s),thennofurtheraxillarysurgeryisneeded.Inaddition,if
onlyaverysmallamountofcancercells(microscopic)arefound,patientsaresafelytreatedwithoutfurther
axillarysurgery.Formostpatientswhoarefoundtohavemorethanafewcancercellsinthesentinellymph
node(s),anaxillarylymphnodedissectionisnecessary.(See"Diagnosis,stagingandtheroleofsentinel
lymphnodebiopsyinthenodalevaluationofbreastcancer".)
TREATMENTAFTERSURGERY
Treatmentaftersurgery,calledadjuvanttreatment,isoftenrecommendedforwomenwithinvasivebreast
cancer.Adjuvanttreatmentisdiscussedinaseparatearticle.(See"Patientinformation:Earlystagebreast
cancertreatmentinpostmenopausalwomen(BeyondtheBasics)"and"Patientinformation:Earlystagebreast
cancertreatmentinpremenopausalwomen(BeyondtheBasics)".)
SURVEILLANCEAFTERINITIALTREATMENT
Afterbeingtreatedforbreastcancer,thereisariskthatbreastcancermayrecuroranewbreastcancermay
develop.Breastcancersurvivorsareadvisedtoseetheirsurgeonand/ormedicaloncologisteverysixmonths
foranexamination.Somepatientsmayrequireexaminationseverythreemonths,especiallywithinthefirst
threeyears.Yourdoctorwilladviseyouontheappropriatefollowupscheduleforyou.
Allpatientstreatedforbreastcancerareadvisedtoperformaselfbreastandchestwallexaminationmonthly.
Patientswhohaveundergoneamastectomywithreconstructionshouldperformanexaminationofthe
reconstructedbreast.Patientstreatedwithamastectomywithoutreconstructionshouldexaminethechest
wall.Theselfexaminationforallpatientsshouldalsoincludecheckingthelymphnodeareas.Youshould
promptlycallyourdoctorornurseifyoufeelanewmass,seeanyrednessoftheskinnotrelatedtoradiation
treatments,orifyouhaveanyquestionsaboutyourselfexamination.
AyearlymammogramshouldbeperformedforallwomenwhohaveundergoneBCToraunilateral
mastectomy.Inmostinstances,mammographyaftermastectomyandbreastreconstructionisusuallynot
recommended.(See"Approachtothepatientfollowingtreatmentforbreastcancer".)
AsummaryoftheAmericanSocietyofClinicalOncology'srecommendationsforsurveillanceafterbreast
cancertreatmentisprovidedinthetable(table1).
WHERETOGETMOREINFORMATION
Yourhealthcareprovideristhebestsourceofinformationforquestionsandconcernsrelatedtoyourmedical
problem.
Thisarticlewillbeupdatedasneededonourwebsite(www.uptodate.com/patients).Relatedtopicsfor
patients,aswellasselectedarticleswrittenforhealthcareprofessionals,arealsoavailable.Someofthemost
relevantarelistedbelow.
PatientlevelinformationUpToDateofferstwotypesofpatienteducationmaterials.
TheBasicsTheBasicspatienteducationpiecesanswerthefourorfivekeyquestionsapatientmight
haveaboutagivencondition.Thesearticlesarebestforpatientswhowantageneraloverviewandwhoprefer
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short,easytoreadmaterials.
Patientinformation:Breastcancer(TheBasics)
Patientinformation:Breastreconstructionaftermastectomy(TheBasics)
Patientinformation:Choosingtreatmentforearlystagebreastcancer(TheBasics)
Patientinformation:Ductalcarcinomainsitu(DCIS)(TheBasics)
BeyondtheBasicsBeyondtheBasicspatienteducationpiecesarelonger,moresophisticated,and
moredetailed.Thesearticlesarebestforpatientswhowantindepthinformationandarecomfortablewith
somemedicaljargon.
Patientinformation:Breastcancerguidetodiagnosisandtreatment(BeyondtheBasics)
Patientinformation:Lymphedemaaftercancersurgery(BeyondtheBasics)
Patientinformation:Locallyadvancedandinflammatorybreastcancer(BeyondtheBasics)
Patientinformation:Earlystagebreastcancertreatmentinpostmenopausalwomen(BeyondtheBasics)
Patientinformation:Earlystagebreastcancertreatmentinpremenopausalwomen(BeyondtheBasics)
ProfessionallevelinformationProfessionallevelarticlesaredesignedtokeepdoctorsandotherhealth
professionalsuptodateonthelatestmedicalfindings.Thesearticlesarethorough,long,andcomplex,and
theycontainmultiplereferencestotheresearchonwhichtheyarebased.Professionallevelarticlesarebest
forpeoplewhoarecomfortablewithalotofmedicalterminologyandwhowanttoreadthesamematerialstheir
doctorsarereading.
ProfessionalLevelInformation:
Overviewofthetreatmentofnewlydiagnosed,nonmetastaticbreastcancer
Atypiaandlobularcarcinomainsitu:Highrisklesionsofthebreast
Breastconservingtherapy
Breastductalcarcinomainsitu:Epidemiology,clinicalmanifestations,anddiagnosis
Ductalcarcinomainsitu:Treatmentandprognosis
Breastreconstruction:Preoperativeassessment
Hormonereceptorsinbreastcancer:Clinicalutilityandguidelinerecommendationstoimprovetestaccuracy
Mastectomy:Indications,types,andconcurrentaxillarylymphnodemanagement
Microinvasivebreastcarcinoma
Diagnosis,stagingandtheroleofsentinellymphnodebiopsyinthenodalevaluationofbreastcancer
Radiationtherapytechniquesfornewlydiagnosed,nonmetastaticbreastcancer
Approachtothepatientfollowingtreatmentforbreastcancer
Thefollowingorganizationsalsoprovidereliablehealthinformation.
NationalCancerInstitute
18004CANCER
(www.nci.nih.gov)
AmericanSocietyofClinicalOncology
(www.cancer.net/portal/site/patient)
NationalComprehensiveCancerNetwork
(www.nccn.org)
AmericanCancerSociety
1800ACS2345
(www.cancer.org)
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NationalLibraryofMedicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)
SusanG.KomenBreastCancerFoundation
(www.komen.org)
PatientsupportThereareanumberofonlineforumswherepatientscanfindinformationandsupportfrom
otherpeoplewithsimilarconditions.
About.comBreastCancerForum
(http://breastcancer.about.com/forum)
Literaturereviewcurrentthrough:Jul2015.|Thistopiclastupdated:Dec2,2013.
ThecontentontheUpToDatewebsiteisnotintendednorrecommendedasasubstituteformedicaladvice,diagnosis,ortreatment.Always
seektheadviceofyourownphysicianorotherqualifiedhealthcareprofessionalregardinganymedicalquestionsorconditions.Theuseof
thiswebsiteisgovernedbytheUpToDateTermsofUse2015UpToDate,Inc.
References
Top
1. ClarkeM,CollinsR,DarbyS,etal.Effectsofradiotherapyandofdifferencesintheextentofsurgeryfor
earlybreastcanceronlocalrecurrenceand15yearsurvival:anoverviewoftherandomisedtrials.Lancet
2005366:2087.
2. Effectsofradiotherapyandsurgeryinearlybreastcancer.Anoverviewoftherandomizedtrials.Early
BreastCancerTrialists'CollaborativeGroup.NEnglJMed1995333:1444.
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