1. Patey’s Mastectomy

2. Patey’s (Radical) Mastectomy Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales) MMSc (Newcastle) Professor of Surgery Department of Surgery King George’s Medical University Lucknow, Uttar Pradesh, India

3. Patey’s Mastectomy

6. Breast Cancer A relaxed approach to local treatment in the last 20 years Loco Regional Recurrence (LRR) represents a biologic disease rather than a treatment failure

7. NEW – Not so New Recognition of the importance of extent and quality of primary surgery in determining outcomes ‘R’ = Residual

8. Local treatment Improved loco regional control Improved survival Improved local treatment – not been a subject of intensive, high profile randomised clinical trials

9. Adjuvant radiotherapy Overgaard et al, NEJM 1997; 337:949 Ragaz et al, NEJM 1997; 337:956 Hellman S, NEJM 1997; 337:996 Radical surgical treatment Quality of life Local treatment + Systemic treatment Survival Breast cancer : the survival

10. Conservation Technique Seek LRR Require intensive radiotherapy Chemotherapy Long term follow-up monitoring

11. Psychological Benefits of Conservation Radiotherapy Outcome Chemotherapy Is this really good  or as hoped 

12. An Alternative is More radical surgery to maximize local control ± Immediate breast reconstruction as cherished Good loco-regional control related to improved survival rates Avoid adjuvant therapies

13. The Benefits Breast conservation treatment unsuitable for 50% patients Oldhoff 1992 Surgery remains necessary to treat large tumors Surgery for unresponsive to chemotherapy Long term adverse effects of high dose radiotherapy Breast Can Res Treat 1998; 47:101 Lower treatment and monitoring cost

15. Breast Conservation – a Commodity Early stage disease – a reference bias Epidemiologically downstage – screen achieved Large breasts – well nourished population Radiotherapy support – overburdened Meticulous surgical technique – sentinel node training Chemotherapy mandate – ensured compliance, subsidy Intensive follow up – education / means

16. LRR / Survival

17. Survival Related to Tumor Size

18. Who developed systemic recurrence ?

19. An outcome at variance Clear survival advantage for those who achieved good loco-regional control A hypothesis which has not been a subject of high profile prospective RCT

20. Overtaken by “new biology” “Breast cancer is systemic from its onset and lymphnode involvement has significance only as an indicator of systemic spread” Fisher

21. Halstedian paradigm Radicality of treatment - panacea for cure Paradigm shift Breast cancer - a systemic disease Fisher’s rhetoric New millenium paradigm Loco-regional recurrence - harbinger of systemic recurrence

22. Equivalence of Radical vs Conservative Equivalent LRR between conservative and radical because of multicentric trials - ? quality control in surgery Euphemism in Group allocation (Milan - Veronesi) : Quadrantectomy, meticulous axillary dissection and high dose post-op radiotherapy = radical mastectomy Powerful, high profile, randomised, multicentric and controlled clinical trials neglect assessment of surgical technique

23. In Summary Radical local treatment contributes significantly to survival Reduced loco-regional recurrence influences survival High quality loco-regional control should be emphasized as is systemic therapy Assessment of surgical techniques should be included in studies in which surgery is a component of therapy

24. David Patey