Radical mastectomy now outdated CMAJ 1997;156:1380 In response to: T. Johnstone We agree with Dr. Johnstone that randomized trials have shown that breast-conserving surgery (BCS) followed by timely radiation therapy (RT) is equivalent to total mastectomy for most patients with early-stage breast cancer. BCS alone, however, results in higher rates of local recurrence[1­5] and higher rates of distant metastatic cancer.[1­3] As described in our article and in a more detailed investigation of variation in the use of BCS within British Columbia,[6] access to RT services was one of several factors influencing the rate of BCS. Women living more than a 2-hour drive from an RT facility had lower rates of BCS in both BC and Ontario. In 1991, the period of the study, 30% of patients in BC lived more than a 2-hour drive from an RT facility, whereas only 6% of patients in Ontario lived this far from an RT facility. Only 4% of patients were treated with BCS alone in BC, as compared with 17% in Ontario. This finding reflects the closer compliance with international[7] and provincial cancer treatment guidelines in BC. To improve access to RT in BC, a new cancer centre with 4 machines opened in the Fraser valley in 1991, another is under construction in Kelowna, 2 new machines are being commissioned in Vancouver and the capacity in Victoria is being doubled. There was also a strong surgeon effect influencing BCS use in BC. This could not be explained by the surgeon's sex, volume of patients treated, academic affiliation or year of graduation from medical school.[6] Our study could not determine whether women faced with the need to travel for RT were not offered or did not choose BCS. It has been shown that patients who participate in the choice of treatment, independent of the choice selected, have less long-term anxiety and depression than women directed to either mastectomy or BCS.[8] Women should be informed of the equivalence of BCS plus RT and total mastectomy in a nonjudgemental way, be assisted to obtain additional information about the advantages and disadvantages of each option and given the time and respect to make the decision for themselves. The issue of resource allocation among treatment, prevention and screening programs is important and must be addressed by society as a whole. Studies such as ours can describe the distribution of resources but cannot answer the question of how to allocate available resources most appropriately. Such questions require evaluation of the efficacy, effectiveness and costs of different interventions and the preferences of individuals and society toward different outcomes. Ivo A. Olivotto, MD T. Gregory Hislop, MD, CM Andrew Coldman, PhD British Columbia Cancer Agency Vancouver, BC Vivek Goel, MD, CM Carol Sawka, MD University of Toronto Toronto, Ont. References 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;333:1456-61. Clark RM, Whelan T, Levine M, et al. Randomized clinical trial of breast irradiation following lumpectomy and axillary dissection for node-negative breast cancer: an update. J Natl Cancer Inst 1996;88:1659-64. Forrest AP, Stewart HJ, Everington D, et al. Randomised controlled trial of conservation therapy for breast cancer: 6-year analysis of the Scottish trial. Lancet 1996;348:708-13. Veronesi U, Luini A, Del Vecchio M, et al. Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med 1993;328:1587-91. Liljegren G, Holmberg L, Adami H-O, et al. Sector resection with or without postoperative radiotherapy for stage I breast cancer: five-year results of a randomized trial. J Natl Cancer Inst 1994;86:717-22. Hislop TG, Olivotto IA, Coldman AJ, et al. Variations in breast conservation surgery for women with axillary node negative breast cancer in British Columbia. Can J Public Health 1996;87:390-4. Treatment of early-stage breast cancer: National Institute of Health Consensus Development Conference. JAMA 1991;265:391-5. Fallowfield LH, Hall A, Maguire GP, et al. Psychological outcomes of different treatment policies in women with early breast cancer outside a clinical trial. BMJ 1990;301:575-80. Send a letter to the editor responding to this letter Envoyez une lettre à la rédaction au sujet de cette lettre | CMAJ May 15, 1997 (vol 156, no 10) / JAMC le 15 mai 1997 (vol 156, no 10) |