Less is more: breast-conserving therapy gains ground.(Gynecology)

SAN ANTONIO -- Treatment of early breast cancer is in the midst of a revolution characterized by a "less is more" philosophy, according to Dr. Umberto Veronesi.

The traditional paradigm in early-stage breast cancer has been to attack the disease using maximal tolerable treatment. But beginning more than 2 decades ago with the publication of the first randomized trials establishing that breast-conserving therapy may safely substitute for radical mastectomy with no increase in mortality, the prevailing philosophy has been shifting to one favoring minimal effective therapy. That's very good news indeed, Dr. Veronesi commented at a breast cancer symposium that was sponsored by the Cancer Therapy and Research Center.

"The purpose of the maximal tolerable treatment approach was to achieve improved survival, but the effect was the opposite because women were terrorized by this treatment. And a terrorized woman is not the best patient. Instead of going to the doctor when they might discover an early tumor, terrorized patients prefer to psychologically remove themselves. We had too many patients who presented with late disease," said Dr. Veronesi, scientific director of the European Institute of Oncology in Milan.

The less-is-more stance has since broadened to include a less mutilating approach to regional lymph node dissection, investigation of various forms of partial breast irradiation as an alternative to the traditional large-field exposure, and less aggressive chemotherapy lasting for several months instead of years.

"The new concept of minimal effective therapy will lead to a better quality of life, which in turn will motivate women toward early detection, which in turn will improve survival," the surgical oncologist asserted.

Dr. Veronesi is considered the founder of breast-conserving therapy. He has published 20-year follow-up data from his seminal clinical trial in which 701 women were randomized to breast-conserving therapy or radical mastectomy. All-cause mortality was 41.7% in the group with breast conservation and a virtually identical 41.2% in those who received mastectomy (N. Engl. J. Med. 347[16]:1227-32, 2002).

"Breast-conserving therapy looks obvious today, but it was not so 30 years ago. Mastectomy was the dogma, and dogma cannot be discussed. Any different approach was considered heretical. I myself had a very difficult time with my proposition," he recalled.