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Indian Journal of Cancer
Medknow Publications on behalf of Indian Cancer Society
ISSN: 0019-509X EISSN: 1998-4774
Vol. 48, Num. 4, 2011, pp. 389-390

Indian Journal of Cancer, Vol. 48, No. 4, October-December, 2011, pp. 389-390

Breast - Editorial

Paradigm shift in surgery for breast cancer: The Indian reality

Consultant Surgical Oncologist, Tata Memorial Hospital, Parel, Mumbai, India
Correspondence Address: N S Nair, Consultant Surgical Oncologist, Tata Memorial Hospital, Parel, Mumbai, India,

Code Number: cn11113

PMID: 22293248
DOI: 10.4103/0019-509X.92244

The latter part of the last millennium was a period of new discoveries in science and medicine, with a new understanding of the cause and treatment of cancer in general. Over the years, there has been a paradigm shift toward more conservative surgery in the treatment for breast cancer. However, despite conclusive level one evidence for the safety of breast conserving surgery (BCS), [1] the Indian surgeon continues to debate the most appropriate surgery for the primary tumor. The authors rightly mention that BCS is not a popular choice among surgeons in India (11-23% versus 60-70% in the west) as compared with data cited from the west. Many previous studies evaluating the acceptance of breast conservation have cited patients′ psychologic distress associated with fear of recurrence as a factor in not recommending BCS. [2]

The earlier trials of breast conservation in Europe [3] had included only tumors of 2.5 cm or less. The NSABP trial [4] later had included tumors up to 4 cm in size. Presently, if the relative size of the tumor to breast volume is adequate, even larger tumors can be considered for BCS. Pre-operative chemotherapy in large operable breast cancers and even in locally advanced tumors can result in a significant decrease in tumor size to allow breast conservation with clear margins. [5],[6] Currently, extended indications of BCS and various oncoplastic techniques are being evaluated. [7] The term oncoplasty includes BCS with either local flaps (displacement procedures) or pedicle latissimus dorsi flaps (for volume correction), which are commonly used for large tumor to-breast volume, multifocal tumors if limited to a single quadrant or centrally located lesions. The initial results in support of oncoplasty are promising, but there is very little evidence available in the published literature to support its use as standard of care. [8]

An important concern after BCS is the cosmetic outcome. This was evaluated in a prospective study, where patient′s perception of satisfaction with their body image following BCS was compared with the clinician′s appraisal of cosmesis. [9] The study noted that as time elapsed, the clinician′s opinion showed a trend toward worsening of cosmesis (P < 0.001), probably due to late changes in breast appearance and feel related to possible post-radiation fibrosis. The patient′s assessment of cosmetic outcome on the other hand showed a trend toward improvement (P = 0.84), suggesting that women who have voluntarily accepted to undergo Breast conservative therapy and are disease-free appear to have a relatively high threshold for accepting ′′unsatisfactory′′ breast cosmesis.

Today, the main deterrents for offering breast conservation to the Indian woman are the logistic and cost constraints for optimum breast radiotherapy and availability of surgical expertise. As noted in this single institution study, the increasing trend toward patients opting for conservation is apparent over the years. [10] But, one must throw caution in the wind and suggest that BCS must only be offered in cases where it is an oncologically safe option and facilities for radiation therapy are available or feasible for the patient to avail. Thus, in a predominantly premenopausal population that presents with breast cancer in India, with median age 47 years, the option of breast conservation wherever feasible must be considered.


1.Jatoi I, Proschan MA. Randomized trials of breast-conserving therapy versus mastectomy for primary breast cancer: A pooled analysis of updated results. Am J Clin Oncol 2005;28:289-94.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Lasry J, Margolese RG. Fear of recurrence, breast-conserving surgery, and the trade-off hypothesis. Cancer 1992;69:2111-5.  Back to cited text no. 2    
3.Veronesi U, Saccozzi R, Del Vecchio M, Banfi A, Clemente C, De Lena M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981;305:6-11.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Fisher B, Anderson S, Bryant J, Margolese RG, Deutsch M, Fisher ER, et al. Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233-41.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Parmar V, Nadkarni MS, Kakade A, Hawaldar R, Badwe RA. Does the patient's opinion differ from the clinicians' regarding breast cosmesis after BCT? Breast J 2010;16:103-4.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Mamounas EP, Anderson SJ, Bea HD. Predictors of locoregional failure (LRF) in patients receiving neoadjuvant chemotherapy (NC): Results from combined analysis of NSABP B-18 and NSABP B-27. ASCO Breast Symposium 2010. Abstract no 90.  Back to cited text no. 6    
7.Parmar V, Hawaldar R, Badwe RA. Safety of Partial Breast Reconstruction in Extended Indications for Conservative Surgery in Breast Cancer. Indian J Surg Oncol 2010;1:256-62.  Back to cited text no. 7    
8.Rietjens M, Urban CA, Rey PC, Mazzarol G, Maisonneuve P, Garusi C, et al. Long-term oncological results of breast conservative treatment with oncoplastic surgery. Breast 2007;16:387-95.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Parmar V, Nadkarni MS, Kakade A, Hawaldar R, Badwe RA. Does the patient's opinion differ from the clinicians' regarding breast cosmesis after BCT? Breast J.2010;16:103-4.  Back to cited text no. 9    
10.Narendra H, Ray S. Breast conserving surgery for breast cancer: Single institution experience from southern India. Indian J Cancer 2011;48:468-75.  Back to cited text no. 10    

Copyright 2011 - Indian Journal of Cancer

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