2. Evidence Based For invasive breast cancer BCT is Tumor excision, axillary node dissection, whole breast radiation Modified mastectomy is total mastectomy and axillary node dissection BCT = Modified Mastectomy, in both Recurrence and OS

3. Recurrence BCT 1-2%/yr - Recurrence is in-breast, 80 % in primary treated field, 20% new primary or regional Post mastectomy - Recurrence is chest wall The recurrences are different biologies, and etiologies The type of recurrence for BCT is eliminated by mastectomy The type of recurrence for mastectomy is eliminated by radiation therapy

4. Recurrence Since these recurrence “rates” are approximately equal, the treatment successes look the same. But if you add radiation to mastectomy then there will be a gain in overall survival, i.e. Mastectomy+Rad is superior to BCT, most effect with node positive. Gain of >5% at 15 years.

5. Radiation Partial breast radiation Eliminates treatment of “out of field” cancers known to exist in 20-40% Provides a shell of inadequate therapeutic radiation ideal for induction of cancer. It should fail to treat each of the distinct risk issues unique to BCT and Mastectomy Predicts an increase in late failures

6. Effect of radiotherapy after breast-conserving surgery (10 trials of BCS  RT) on local recurrence and on breast cancer mortality 6097 women with node-negative disease

7. Effect of radiotherapy after breast-conserving surgery (10 trials of BCS  RT) on local recurrence and on breast cancer mortality 1214 women with node-positive disease

8. Effect of radiotherapy after mastectomy and axillary clearance (25 trials of Mast+AC  RT) on local recurrence and on breast cancer mortality 1428 women with node-negative disease

9. Effect of radiotherapy after mastectomy and axillary clearance (25 trials of Mast+AC  RT) on local recurrence and on breast cancer mortality 8505 women with node-positive disease

10. Effect of radiotherapy on breast cancer mortality and on all-cause mortality after mastectomy with axillary clearance (Mast+AC  RT) 8505 women with node-positive disease

11. Radiotherapy after mastectomy with axillary clearance (Mast+AC  RT) in all women (9933 women, 86% with node-positive disease)

12. Radiotherapy after mastectomy with axillary clearance (Mast+AC  RT) in women with node-negative disease (1428 women)

13. Radiotherapy after mastectomy with axillary clearance (Mast+AC  RT) in all women with node-positive disease (8505 women, many with the actual number of involved nodes unknown)

14. Radiotherapy after mastectomy with axillary clearance (Mast+AC  RT) in women with 1-3 involved lymph nodes (pN1-3) (1890 women)

15. Radiotherapy after mastectomy with axillary clearance (Mast+AC  RT) in women with 4 or more involved lymph nodes (pN4+) (1868 women)