Breast cancer statistics: use and misuse.

Statistics can be manipulated, by using various methods of reporting, to support almost any type of regime in breast cancer. The basis for statistical calculations include: the definition of the population of patients treated, the time used for starting calculations, the exact nature of the treatment used and any adjuvant therapy, the prognostic parameters utilized, the importance of long-term follow-ups, adequate number of cases, therapy standardization and pathological reporting, methods of evaluating survival such as observed or crude, relative and no evidence of disease, methods of calculating observed survival rates such as absolute, actuarial or life-table and Kaplan Meier or product limit, statistical evaluation for planned improvement with acceptable Type I and Type II errors, and the use of arithmetic and logarithmic scales in plotting statistics. Purveyors of innovative methods for the treatment of breast cancer aimed at preserving part or all of the breast as cosmetic alternatives to mastectomy, by limited operations with and without primary radiotherapy, have a most appealing argument to a woman with breast cancer. To determine if such procedures are justifiable alternatives to selective mastectomies and reconstructions, detailed, long-term statistical data on large numbers of cases must be available and end-results comparisons of various therapeutic modalities must be made on the basis of comparable statistical data.

The Field Liaison Program of the American College of Surgeons.

The Liaison Fellow/Associate Program is a viable means of upgrading hospital cancer programs. In no way does it usurp administrative channels of hospital staffs but provides a mechanism of receiving and utilizing activities which have been successful in other hospitals. I urge all of you seriously to involve your hospitals in this program.

The effect of pregnancy on the prognosis of carcinoma of the breast following radical mastectomy.

During the interval from 1940 to 1970, 41 patients treated for primary operable carcinoma of the breast had subsequent pregnancies. Of 27 patients with axillary nodes negative for tumor, nine had first trimester abortions and 14 had pregnancies occur less than two years following mastectomy. Fourteen patients had axillary nodes positive for tumor, seven having first trimester abortions and eight pregnancies having occurred within two years of mastectomy. No detrimental effect of subsequent pregnancy could be demonstrated, even among patients with positive axillary nodes or among those whose pregnancies occurred less than two years following mastectomy. Abortion could not be demonstrated to improve the survival rate. We conclude that pregnancy need not be avoided or terminated among those patients who are apparently free of a recurrence after undergoing treatment for carcinoma of the breast.

Rehabilitation and continuing care of cancer patients.

Health professionals are responsible for helping cancer patients and their families readapt to society. Frequently, coping with alcoholism is an integral facet of the rehabilitative process, and in this respect a patient's family often presents more of a problem than does the patient himself. Physicians have shown a lack of knowledge in detecting and dealing with the alcohol problems of their patients. Health professionals involved in the management of patients with cancer must learn to recognize alcoholism to ensure that the problem is referred to an organization or individual who will cope with it adequately. Volunteer groups such as Alcoholics Anonymous, as well as the clergy, some psychiatrists, psychologists, and sociologists, have demonstrated expertise in dealing with alcoholism.

Staging of cancer of the colon and cancer of the rectum.

A retrospective analysis of 1,826 cases (924 colon, 902 rectal) from ten institutions provided the basis of this study on the staging of cancer of the colon and rectum. The general rules of the American Joint Committee on the relationship between times and the staging of cancer have been followed. These represent modifications of the originally formulated TNM system of the Union Internationale Contre Le Cancer (UICC) which has been designed as a clinical-diagnostic classification, not applicable to cancer of inaccessible sites or structures requiring postsurgical treatment pathologic assessment of therapeutically removed specimens. Inadequacies of the clinical data requested for our study required adoption of the pTNM evaluation method of classification. Multiple regression analysis of the data demonstrated a relationship between survival and the following: depth of penetration (T), status of regional lymph nodes (N), and presence or absence of distant metastasis (M). This was similar for both sites. Basically, for the rectum it was in consonance with the original Dukes' classification (A, B, and C), and was remarkably applicable to the colon. The survival data for the two sites were so similar as to suggest the use of one set of pTNM categories not only for the postsurgical-treatment pathologic evaluation, but also for the stage grouping definitions. Strongly recommended for cancer of all sites is the development of General Oncology Data Forms to be included in the clinical charts and records of all patients with cancer.

Intraductal carcinoma. Long-term follow-up after treatment by biopsy alone.

A follow-up period averaging 21.6 years was obtained for patients with low-grade papillary intraductal carcinoma initially treated only by biopsy between 1940 and 1950. Subsequent carcinoma was diagnosed in the same breast in seven of the ten patients after an average interval of 9.7 years. Six of the seven subsequent carcinomas were invasive. Two of the patients died of metastatic carcinoma and two were known to be alive with metastases when last contacted. Three patients were without carcinoma following mastectomy. When these results were combined with the few reports available in the literature, it appeared that at least 39% of patients with intraductal carcinoma treated by biopsy alone subsequently had clinically evident carcinoma, invariably in the same breat, with an average latent period of about ten years. This was undoubtedly a result of the multicentric nature of the disease in many patients.

Selection of treatment regimens for women with potentially curable breast carcinoma.

Five-year survival rates for all Iowa breast cancer patients diagnosed in 1969 are substantially better than most published figures. Partly, this is because more Iowa patients came to treatment early before they developed diagnosable metastases. There also, however, were particularly good results for radical mastectomy compared to modified operations and when axillary metastases were present the results were much the best when supervoltage radiation followed the radical operation.

Physical and psychologic readjustment after mastectomy: an evaluation of Memorial Hospitals' PMRG program.

Memorial Hospital in New York City, the clinical section of the Memorial Sloan-Kettering Cancer Center, has developed a Post-Mastectomy Rehabilitation Group (PMRG) Program. The PMRG Program is comprised of a series of structured exercise, information, discussion, and group therapy sessions conducted by a social worker, nurse, physical therapist, and a volunteer from Reach to Recovery. The specific purposes of the program are to help a patient to begin to regain functional use of her arm and shoulder on the affected side, and to adapt functionally, psychologically, and emotionally to the loss of her breast and to the diagnosis of cancer in the shortest time possible. Approximately 1,700 women who underwent mastectomy participated in the program between 1970 and 1974. Some results and conclusions are: the patient's age and type of operation are related to physical recovery, resumption of normal activities, return to work, and emotional stress; 84% (661 of 790 patients) resumed normal activities within the four-month postoperative period; 74% (237 of 317 patients) returned to work (full time) within three months of their mastectomies; 13% (52 of 406 patients) experienced moderate or severe emotional stress; activity per se (any activity, doing something, keeping busy) affects readjustment; the apparent disadvantage of greater trauma with more extensive surgery may be more than compensated for by the relatively young age of that population, and the relatively less physical trauma and injury, resulting from simple mastectomies may be overshadowed by the patient's age and general physical condition; 98% (284 of 291 patients) reported the PMRG program helpful.

Recurrent operable breast cancer following incomplete mastectomy.

Forty patients have been treated with recurrent operable breast cancer after having undergone procedures less extensive than modified radical mastectomy as a treatment of the primary, with or without radiation therapy. Initial pathology was invasive cancer in 21 patients, and treatment (excision or simple mastectomy, with or without radiation therapy) has been offered as the treatment of choice. Completion of radical mastectomy was done here in 30 patients, extended radical mastectomy in 3, and local excision in 7. Eleven received postoperative radiation therapy. The overall 5-year survival rate from the time of treatment, free of disease, was 40 per cent, and the 10-year survival rate was 20 per cent. If initial treatment included radiation therapy, survival was improved (12/25 vs 4/15 having no radiation therapy). Axillary nodal involvement was extensive, with 13 patients having positive level III nodes. Such patients should be followed closely in order to detect recurrence earlier. Adjuvant radiation therapy and chemotherapy trials post mastectomy should be evaluated in the hope of improving survival.

The Post-Mastectomy Rehabilitation Group program. Structure, procedure, and population demography.

Memorial Hospital, New York City, clinical section of the Memorial Sloan-Kettering Cancer Center, has developed a Post-Mastectomy Rehabilitation Group (PMRG) which provides a comprehensive structure program to enable the mastectomy patient to regain functional use of her arm and shoulder on the affected side, and to adapt functionally, psychologically, and emotionally to the loss of her breast and the diagnosis of cancer in the shortest time possible. This first segment of an evaluation of the program outlines the PMRG structure and operating procedures and presents basic demographic data (age, type of mastectomy, preoperative activity status) for 863 of the 1,400 mastectomy patients who attended the program since inception in 1970. Additional reports will focus on the physical and psychologic aspects of recovery and readjustment.

Recurrent cystosarcoma phyllodes: a clinicopathologic study of 32 cases.

A retrospective study was made of recurrent mammary cystosarcoma phyllodes seen at Memorial Sloan-Kettering Cancer Center from 1932 to 1972. Clinicopathologic findings, clinical course, treatment, and survival are described. It is apparent that cystosarcomas may recur and several years may elapse between reucrrences. We found that 18% of the benign and 8% of the malignant cystosarcomas recurred and malignant "transformation" occurred in two of the 28 recurrent benign cystosarcomas.

Ten-year results of the treatment of primary operable breast carcinoma: A summary of 304 patients evaluated by the TNM system.

After all records of patients with breast cancer who received primary treatment at Memorial Hospital in 1960 were reviewed, 304 women with operable, infiltrating carcinoma were identified and classified clinically according to the TNM system of the American Joint Committee for Cancer Staging and End Results Reporting. There were 66 patients (22%) classified under Stage I, 176 (58%) under Stage II, and 62 (20%) under Stage III. There were 82 patients (27%) in whom the nodal status was misclassified clinically. The observed 10-year survival was 59.7%. The 10-year end results (with 95% confidence limits) diminished significantly in relation to advancing clinical stage of disease--90.9% (+/-6.9%) for Stage I, 57.1% (+/-7.3%) for Stage II, and 33.9% (+/-11.8%) for Stage III patients. The 10-year survival in patients with pathologically negative axillary nodes was 71.5%, and in the patients with pathologically positive axillary nodes, 48.3%.

Prognosis of the second breast cancer. The role of previous exposure to the first primary.

With increasing evidence that cancer patients respond immunologically to their cancers, it seemed interesting to investigate whether or not the course of the second cancer differed from that of the first. If we assume that, in analogy to mammary cancer in the mouse, the cells of human breast cancers carry shared antigens (although this is by no means certain), we could expect that sensitization of the patient induced by the first cancer would enhance his immune response to the second and that this might be reflected in an altered clinical course. We evaluated 82 patients with a second breast cancer and found no difference in the course of the second cancer as compared with the first.