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Surgery Following Primary Systemic Therapy: How to Increase Breast Conservation Rate

  • Rosa Di MiccoEmail author
  • Oreste Davide Gentilini
Chapter
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Abstract

Primary systemic therapy (PST) in breast cancer treatment can be used to downstage tumor size and increase the rate of breast conservation with consequent less morbidity and better aesthetic outcome. Current data on locoregional recurrence (LRR) are encouraging, showing that breast conservation (BCS) after PST is a safe option with no difference in overall survival (OS) and disease-free survival (DFS) when compared to mastectomy. When BCS is considered challenging or impossible at first instance, PST could be a good solution to enable BCS and spare the patient from mastectomy. Patient selection should be based on biological and anatomical factors, considering both tumor-to-breast ratio and the breast tumors for whom tumor downstaging is expected after PST (i.e., hormone receptor negative, high-grade, Her2-positive or triple negative breast cancer). However, for some subgroups of patients, primary surgery remains preferable (i.e. extensive microcalcifications, lobular carcinoma). A reliable local re-staging after PST, accurately reflecting the extent of residual disease, is crucial for an optimal surgery: physical examination, ultrasound, mammography, and magnetic resonance imaging (MRI) should guide the surgeon. The surgical excision should include residual tumor or part of the initial tumor bed around the clip that should be placed before PST. Surgical complications after PST are the same of ordinary breast surgery, despite a more challenging procedure due to the lack of clearly palpable margins that can reduce surgical precision and the difficulty of obtaining negative margins. In order to increase the breast conservation rate, the surgeons should work on: patient selection, accurate pre- and post-PST staging, surgeon-related factors, tumor-related factors, and patient-related factors. A better understanding of the PST potential benefits and of the equivalence of BCS and mastectomy after PST could improve aesthetic outcome and quality of life in more and more breast cancer patients.

Keywords

Primary systemic therapy Breast-conserving surgery Breast conservation rate Locoregional recurrence 

References

  1. 1.
    Kiebert GM, de Haes JC, van de Velde CJ. The impact of breast-conserving treatment and mastectomy on the quality of life of early-stage breast cancer patients: a review. J Clin Oncol. 1991;9(6):1059–70.PubMedGoogle Scholar
  2. 2.
    Kling KM, Ostrzega N, Schmit P. Breast conservation after induction chemotherapy for locally advanced breast cancer. Am Surg. 1997;63(10):861–4.PubMedGoogle Scholar
  3. 3.
    Schwartz GF, Birchansky CA, Komarnicky LT, Mansfield CM, Cantor RI, Biermann WA, et al. Induction chemotherapy followed by breast conservation for locally advanced carcinoma of the breast. Cancer. 1994;73(2):362–9.PubMedGoogle Scholar
  4. 4.
    Makris A, Powles TJ, Ashley SE, Chang J, Hickish T, Tidy VA, et al. A reduction in the requirements for mastectomy in a randomized trial of neoadjuvant chemoendocrine therapy in primary breast cancer. Ann Oncol. 1998;9(11):1179–84.PubMedGoogle Scholar
  5. 5.
    Bélembaogo E, Feillel V, Chollet P, Curé H, Verrelle P, Kwiatkowski F, et al. Neoadjuvant chemotherapy in 126 operable breast cancers. Eur J Cancer. 1992;28A(4–5):896–900.PubMedGoogle Scholar
  6. 6.
    Scholl SM, Fourquet A, Asselain B, Pierga JY, Vilcoq JR, Durand JC, et al. Neoadjuvant versus adjuvant chemotherapy in premenopausal patients with tumours considered too large for breast conserving surgery: preliminary results of a randomised trial: S6. Eur J Cancer. 1994;30A(5):645–52.PubMedGoogle Scholar
  7. 7.
    Smith IE, Jones AL, O’Brien ME, McKinna JA, Sacks N, Baum M. Primary medical (neo-adjuvant) chemotherapy for operable breast cancer. Eur J Cancer. 1993;29A(12):1796–9.PubMedGoogle Scholar
  8. 8.
    Singletary SE, McNeese MD, Hortobagyi GN. Feasibility of breast-conservation surgery after induction chemotherapy for locally advanced breast carcinoma. Cancer. 1992;69(11):2849–52.PubMedGoogle Scholar
  9. 9.
    Fisher B, Brown A, Mamounas E, Wieand S, Robidoux A, Margolese RG, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol. 1997;15(7):2483–93.PubMedGoogle Scholar
  10. 10.
    Bleicher RJ, Ruth K, Sigurdson ER, Daly JM, Boraas M, Anderson PR, et al. Breast conservation versus mastectomy for patients with T3 primary tumors (>5 cm): a review of 5685 medicare patients. Cancer. 2016;122(1):42–9.PubMedGoogle Scholar
  11. 11.
    Redden MH, Fuhrman GM. Neoadjuvant chemotherapy in the treatment of breast cancer. Surg Clin North Am. 2013;93(2):493–9.PubMedGoogle Scholar
  12. 12.
    King TA, Morrow M. Surgical issues in patients with breast cancer receiving neoadjuvant chemotherapy. Nat Rev Clin Oncol. 2015;12(6):335–43.PubMedGoogle Scholar
  13. 13.
    Vaidya JS, Massarut S, Vaidya HJ, Alexander EC, Richards T, Caris JA, et al. Rethinking neoadjuvant chemotherapy for breast cancer. BMJ. 2018;360:j5913.PubMedGoogle Scholar
  14. 14.
    Mauri D, Pavlidis N, Ioannidis JP. Neoadjuvant versus adjuvant systemic treatment in breast cancer: a meta-analysis. J Natl Cancer Inst. 2005;97(3):188–94.PubMedGoogle Scholar
  15. 15.
    Mieog JS, van der Hage JA, van de Velde CJ. Neoadjuvant chemotherapy for operable breast cancer. Br J Surg. 2007;94(10):1189–200.PubMedGoogle Scholar
  16. 16.
    (EBCTCG) EBCTCG. Long-term outcomes for neoadjuvant versus adjuvant chemotherapy in early breast cancer: meta-analysis of individual patient data from ten randomised trials. Lancet Oncol. 2018;19(1):27–39.Google Scholar
  17. 17.
    Bear HD, Anderson S, Brown A, Smith R, Mamounas EP, Fisher B, et al. The effect on tumor response of adding sequential preoperative docetaxel to preoperative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project Protocol B-27. J Clin Oncol. 2003;21(22):4165–74.PubMedGoogle Scholar
  18. 18.
    Jackisch C, von Minckwitz G, Eidtmann H, Costa SD, Raab G, Blohmer JU, et al. Dose-dense biweekly doxorubicin/docetaxel versus sequential neoadjuvant chemotherapy with doxorubicin/cyclophosphamide/docetaxel in operable breast cancer: second interim analysis. Clin Breast Cancer. 2002;3(4):276–80.PubMedGoogle Scholar
  19. 19.
    Chen AM, Meric-Bernstam F, Hunt KK, Thames HD, Oswald MJ, Outlaw ED, et al. Breast conservation after neoadjuvant chemotherapy: the MD Anderson cancer center experience. J Clin Oncol. 2004;22(12):2303–12.PubMedGoogle Scholar
  20. 20.
    Sun Y, Liao M, He L, Zhu C. Comparison of breast-conserving surgery with mastectomy in locally advanced breast cancer after good response to neoadjuvant chemotherapy: a PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2017;96(43):e8367.Google Scholar
  21. 21.
    Boughey JC, Peintinger F, Meric-Bernstam F, Perry AC, Hunt KK, Babiera GV, et al. Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg. 2006;244(3):464–70.PubMedPubMedCentralGoogle Scholar
  22. 22.
    Botteri E, Veronesi P, Vila J, Rotmensz N, Galimberti V, Thomazini MV, et al. Improved prognosis of young patients with breast cancer undergoing breast-conserving surgery. Br J Surg. 2017;104(13):1802–10.PubMedGoogle Scholar
  23. 23.
    van der Hage JA, van de Velde CJ, Julien JP, Tubiana-Hulin M, Vandervelden C, Duchateau L. Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer trial 10902. J Clin Oncol. 2001;19(22):4224–37.PubMedGoogle Scholar
  24. 24.
    Baselga J, Bradbury I, Eidtmann H, Di Cosimo S, de Azambuja E, Aura C, et al. Lapatinib with trastuzumab for HER2-positive early breast cancer (NeoALTTO): a randomised, open-label, multicentre, phase 3 trial. Lancet. 2012;379(9816):633–40.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Untch M, Loibl S, Bischoff J, Eidtmann H, Kaufmann M, Blohmer JU, et al. Lapatinib versus trastuzumab in combination with neoadjuvant anthracycline-taxane-based chemotherapy (GeparQuinto, GBG 44): a randomised phase 3 trial. Lancet Oncol. 2012;13(2):135–44.PubMedGoogle Scholar
  26. 26.
    Katz SJ, Lantz PM, Janz NK, Fagerlin A, Schwartz K, Liu L, et al. Patient involvement in surgery treatment decisions for breast cancer. J Clin Oncol. 2005;23(24):5526–33.PubMedGoogle Scholar
  27. 27.
    Gianni L, Eiermann W, Semiglazov V, Manikhas A, Lluch A, Tjulandin S, et al. Neoadjuvant chemotherapy with trastuzumab followed by adjuvant trastuzumab versus neoadjuvant chemotherapy alone, in patients with HER2-positive locally advanced breast cancer (the NOAH trial): a randomised controlled superiority trial with a parallel HER2-negative cohort. Lancet. 2010;375(9712):377–84.PubMedGoogle Scholar
  28. 28.
    Gianni L, Pienkowski T, Im YH, Roman L, Tseng LM, Liu MC, et al. Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (NeoSphere): a randomised multicentre, open-label, phase 2 trial. Lancet Oncol. 2012;13(1):25–32.PubMedGoogle Scholar
  29. 29.
    Untch M, Fasching PA, Konecny GE, Hasmüller S, Lebeau A, Kreienberg R, et al. Pathologic complete response after neoadjuvant chemotherapy plus trastuzumab predicts favorable survival in human epidermal growth factor receptor 2-overexpressing breast cancer: results from the TECHNO trial of the AGO and GBG study groups. J Clin Oncol. 2011;29(25):3351–7.PubMedGoogle Scholar
  30. 30.
    von Minckwitz G, Darb-Esfahani S, Loibl S, Huober J, Tesch H, Solbach C, et al. Responsiveness of adjacent ductal carcinoma in situ and changes in HER2 status after neoadjuvant chemotherapy/trastuzumab treatment in early breast cancer--results from the GeparQuattro study (GBG 40). Breast Cancer Res Treat. 2012;132(3):863–70.Google Scholar
  31. 31.
    Schneeweiss A, Chia S, Hickish T, Harvey V, Eniu A, Hegg R, et al. Pertuzumab plus trastuzumab in combination with standard neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in patients with HER2-positive early breast cancer: a randomized phase II cardiac safety study (TRYPHAENA). Ann Oncol. 2013;24(9):2278–84.PubMedGoogle Scholar
  32. 32.
    Liedtke C, Mazouni C, Hess KR, André F, Tordai A, Mejia JA, et al. Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin Oncol. 2008;26(8):1275–81.PubMedGoogle Scholar
  33. 33.
    von Minckwitz G, Schneeweiss A, Loibl S, Salat C, Denkert C, Rezai M, et al. Neoadjuvant carboplatin in patients with triple-negative and HER2-positive early breast cancer (GeparSixto; GBG 66): a randomised phase 2 trial. Lancet Oncol. 2014;15(7):747–56.Google Scholar
  34. 34.
    Silver DP, Richardson AL, Eklund AC, Wang ZC, Szallasi Z, Li Q, et al. Efficacy of neoadjuvant cisplatin in triple-negative breast cancer. J Clin Oncol. 2010;28(7):1145–53.PubMedPubMedCentralGoogle Scholar
  35. 35.
    Byrski T, Gronwald J, Huzarski T, Grzybowska E, Budryk M, Stawicka M, et al. Pathologic complete response rates in young women with BRCA1-positive breast cancers after neoadjuvant chemotherapy. J Clin Oncol. 2010;28(3):375–9.PubMedGoogle Scholar
  36. 36.
    Chen XS, Nie XQ, Chen CM, Wu JY, Wu J, Lu JS, et al. Weekly paclitaxel plus carboplatin is an effective nonanthracycline-containing regimen as neoadjuvant chemotherapy for breast cancer. Ann Oncol. 2010;21(5):961–7.PubMedGoogle Scholar
  37. 37.
    Chang HR, Glaspy J, Allison MA, Kass FC, Elashoff R, Chung DU, et al. Differential response of triple-negative breast cancer to a docetaxel and carboplatin-based neoadjuvant treatment. Cancer. 2010;116(18):4227–37.PubMedGoogle Scholar
  38. 38.
    Untch M, Jackisch C, Schneeweiss A, Conrad B, Aktas B, Denkert C, et al. Nab-paclitaxel versus solvent-based paclitaxel in neoadjuvant chemotherapy for early breast cancer (GeparSepto-GBG 69): a randomised, phase 3 trial. Lancet Oncol. 2016;17(3):345–56.PubMedGoogle Scholar
  39. 39.
    Cortazar P, Zhang L, Untch M, Mehta K, Costantino JP, Wolmark N, et al. Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis. Lancet. 2014;384(9938):164–72.PubMedGoogle Scholar
  40. 40.
    Mieog JS, van der Hage JA, van de Velde CJ. Preoperative chemotherapy for women with operable breast cancer. Cochrane Database Syst Rev. 2007;2:CD005002.Google Scholar
  41. 41.
    von Minckwitz G, Untch M, Nüesch E, Loibl S, Kaufmann M, Kümmel S, et al. Impact of treatment characteristics on response of different breast cancer phenotypes: pooled analysis of the German neo-adjuvant chemotherapy trials. Breast Cancer Res Treat. 2011;125(1):145–56.Google Scholar
  42. 42.
    von Minckwitz G, Untch M, Blohmer JU, Costa SD, Eidtmann H, Fasching PA, et al. Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes. J Clin Oncol. 2012;30(15):1796–804.Google Scholar
  43. 43.
    Mittendorf EA, Buchholz TA, Tucker SL, Meric-Bernstam F, Kuerer HM, Gonzalez-Angulo AM, et al. Impact of chemotherapy sequencing on local-regional failure risk in breast cancer patients undergoing breast-conserving therapy. Ann Surg. 2013;257(2):173–9.PubMedPubMedCentralGoogle Scholar
  44. 44.
    Golshan M, Cirrincione CT, Sikov WM, Carey LA, Berry DA, Overmoyer B, et al. Impact of neoadjuvant therapy on eligibility for and frequency of breast conservation in stage II-III HER2-positive breast cancer: surgical results of CALGB 40601 (Alliance). Breast Cancer Res Treat. 2016;160(2):297–304.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Smith BL. Neoadjuvant versus adjuvant systemic therapy for operable breast cancer: equivalent outcomes? Ann Surg. 2013;257(2):180–1.PubMedGoogle Scholar
  46. 46.
    Adrada BE, Huo L, Lane DL, Arribas EM, Resetkova E, Yang W. Histopathologic correlation of residual mammographic microcalcifications after neoadjuvant chemotherapy for locally advanced breast cancer. Ann Surg Oncol. 2015;22(4):1111–7.PubMedGoogle Scholar
  47. 47.
    Goldberg H, Zandbank J, Kent V, Leonov-Polak M, Livoff A, Chernihovsky A, et al. Chemotherapy may eradicate ductal carcinoma in situ (DCIS) but not the associated microcalcifications. Eur J Surg Oncol. 2017;43(8):1415–20.PubMedGoogle Scholar
  48. 48.
    Kaufmann M, von Minckwitz G, Bear HD, Buzdar A, McGale P, Bonnefoi H, et al. Recommendations from an international expert panel on the use of neoadjuvant (primary) systemic treatment of operable breast cancer: new perspectives 2006. Ann Oncol. 2007;18(12):1927–34.PubMedGoogle Scholar
  49. 49.
    Keune JD, Jeffe DB, Schootman M, Hoffman A, Gillanders WE, Aft RL. Accuracy of ultrasonography and mammography in predicting pathologic response after neoadjuvant chemotherapy for breast cancer. Am J Surg. 2010;199(4):477–84.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Eisenhauer EA, Therasse P, Bogaerts J, Schwartz LH, Sargent D, Ford R, et al. New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer. 2009;45(2):228–47.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Chagpar AB, Middleton LP, Sahin AA, Dempsey P, Buzdar AU, Mirza AN, et al. Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy. Ann Surg. 2006;243(2):257–64.PubMedPubMedCentralGoogle Scholar
  52. 52.
    Fukuda T, Horii R, Gomi N, Miyagi Y, Takahashi S, Ito Y, et al. Accuracy of magnetic resonance imaging for predicting pathological complete response of breast cancer after neoadjuvant chemotherapy: association with breast cancer subtype. Springerplus. 2016;5:152.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Straver ME, Loo CE, Rutgers EJ, Oldenburg HS, Wesseling J, Vrancken Peeters MJ, et al. MRI-model to guide the surgical treatment in breast cancer patients after neoadjuvant chemotherapy. Ann Surg. 2010;251(4):701–7.PubMedGoogle Scholar
  54. 54.
    Schaefgen B, Mati M, Sinn HP, Golatta M, Stieber A, Rauch G, et al. Can routine imaging after neoadjuvant chemotherapy in breast Cancer predict pathologic complete response? Ann Surg Oncol. 2016;23(3):789–95.PubMedGoogle Scholar
  55. 55.
    Marinovich ML, Macaskill P, Irwig L, Sardanelli F, von Minckwitz G, Mamounas E, et al. Meta-analysis of agreement between MRI and pathologic breast tumour size after neoadjuvant chemotherapy. Br J Cancer. 2013;109(6):1528–36.PubMedPubMedCentralGoogle Scholar
  56. 56.
    Heil J, Kümmel S, Schaefgen B, Paepke S, Thomssen C, Rauch G, et al. Diagnosis of pathological complete response to neoadjuvant chemotherapy in breast cancer by minimal invasive biopsy techniques. Br J Cancer. 2015;113(11):1565–70.PubMedPubMedCentralGoogle Scholar
  57. 57.
    Prati R, Minami CA, Gornbein JA, Debruhl N, Chung D, Chang HR. Accuracy of clinical evaluation of locally advanced breast cancer in patients receiving neoadjuvant chemotherapy. Cancer. 2009;115(6):1194–202.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Kwong MS, Chung GG, Horvath LJ, Ward BA, Hsu AD, Carter D, et al. Postchemotherapy MRI overestimates residual disease compared with histopathology in responders to neoadjuvant therapy for locally advanced breast cancer. Cancer J. 2006;12(3):212–21.PubMedGoogle Scholar
  59. 59.
    Yuan Y, Chen XS, Liu SY, Shen KW. Accuracy of MRI in prediction of pathologic complete remission in breast cancer after preoperative therapy: a meta-analysis. AJR Am J Roentgenol. 2010;195(1):260–8.PubMedGoogle Scholar
  60. 60.
    Esserman LE, d’Almeida M, Da Costa D, Gerson DM, Poppiti RJ. Mammographic appearance of microcalcifications: can they change after neoadjuvant chemotherapy? Breast J. 2006;12(1):86–7.PubMedGoogle Scholar
  61. 61.
    Moskovic EC, Mansi JL, King DM, Murch CR, Smith IE. Mammography in the assessment of response to medical treatment of large primary breast cancer. Clin Radiol. 1993;47(5):339–44.PubMedGoogle Scholar
  62. 62.
    Li JJ, Chen C, Gu Y, Di G, Wu J, Liu G, et al. The role of mammographic calcification in the neoadjuvant therapy of breast cancer imaging evaluation. PLoS One. 2014;9(2):e88853.PubMedPubMedCentralGoogle Scholar
  63. 63.
    Weiss A, Lee KC, Romero Y, Ward E, Kim Y, Ojeda-Fournier H, et al. Calcifications on mammogram do not correlate with tumor size after neoadjuvant chemotherapy. Ann Surg Oncol. 2014;21(10):3310–6.PubMedGoogle Scholar
  64. 64.
    Marinovich ML, Houssami N, Macaskill P, Sardanelli F, Irwig L, Mamounas EP, et al. Meta-analysis of magnetic resonance imaging in detecting residual breast cancer after neoadjuvant therapy. J Natl Cancer Inst. 2013;105(5):321–33.PubMedGoogle Scholar
  65. 65.
    Rosen EL, Blackwell KL, Baker JA, Soo MS, Bentley RC, Yu D, et al. Accuracy of MRI in the detection of residual breast cancer after neoadjuvant chemotherapy. AJR Am J Roentgenol. 2003;181(5):1275–82.PubMedGoogle Scholar
  66. 66.
    Weatherall PT, Evans GF, Metzger GJ, Saborrian MH, Leitch AM. MRI vs. histologic measurement of breast cancer following chemotherapy: comparison with x-ray mammography and palpation. J Magn Reson Imaging. 2001;13(6):868–75.PubMedGoogle Scholar
  67. 67.
    Marszalek D, Noël JC, Simon P. [Post operative complications after neoadjuvant systemic therapy in primary breast cancer treatment – case-control study]. Rev Med Brux. 2016;37(6):469–75.Google Scholar
  68. 68.
    Abt NB, Flores JM, Baltodano PA, Sarhane KA, Abreu FM, Cooney CM, et al. Neoadjuvant chemotherapy and short-term morbidity in patients undergoing mastectomy with and without breast reconstruction. JAMA Surg. 2014;149(10):1068–76.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Boughey JC, McCall LM, Ballman KV, Mittendorf EA, Ahrendt GM, Wilke LG, et al. Tumor biology correlates with rates of breast-conserving surgery and pathologic complete response after neoadjuvant chemotherapy for breast cancer: findings from the ACOSOG Z1071 (Alliance) Prospective Multicenter Clinical Trial. Ann Surg. 2014;260(4):608–14; discussion 14–6.PubMedPubMedCentralGoogle Scholar
  70. 70.
    Chiba A, Hoskin TL, Heins CN, Hunt KK, Habermann EB, Boughey JC. Trends in neoadjuvant endocrine therapy use and impact on rates of breast conservation in hormone receptor-positive breast Cancer: a National Cancer Data Base Study. Ann Surg Oncol. 2017;24(2):418–24.PubMedGoogle Scholar
  71. 71.
    Criscitiello C, Curigliano G, Burstein HJ, Wong S, Esposito A, Viale G, et al. Breast conservation following neoadjuvant therapy for breast cancer in the modern era: are we losing the opportunity? Eur J Surg Oncol. 2016;42(12):1780–6.Google Scholar
  72. 72.
    Criscitiello C, Azim HA, Agbor-tarh D, de Azambuja E, Piccart M, Baselga J, et al. Factors associated with surgical management following neoadjuvant therapy in patients with primary HER2-positive breast cancer: results from the NeoALTTO phase III trial. Ann Oncol. 2013;24(8):1980–5.PubMedGoogle Scholar
  73. 73.
    Tan MP. Is there an ideal breast conservation rate for the treatment of breast cancer? Ann Surg Oncol. 2016;23(9):2825–31.PubMedPubMedCentralGoogle Scholar
  74. 74.
    McGuire KP, Santillan AA, Kaur P, Meade T, Parbhoo J, Mathias M, et al. Are mastectomies on the rise? A 13-year trend analysis of the selection of mastectomy versus breast conservation therapy in 5865 patients. Ann Surg Oncol. 2009;16(10):2682–90.PubMedGoogle Scholar
  75. 75.
    Feigelson HS, James TA, Single RM, Onitilo AA, Aiello Bowles EJ, Barney T, et al. Factors associated with the frequency of initial total mastectomy: results of a multi-institutional study. J Am Coll Surg. 2013;216(5):966–75.PubMedPubMedCentralGoogle Scholar
  76. 76.
    Morrow M, Harris JR, Schnitt SJ. Surgical margins in lumpectomy for breast cancer – bigger is not better. N Engl J Med. 2012;367(1):79–82.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Breast UnitSan Raffaele University and Research HospitalMilanItaly
  2. 2.Department of Clinical Medicine and SurgeryUniversity of Naples Federico IINaplesItaly
  3. 3.Breast UnitSan Raffaele University and Research HospitalMilanItaly

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