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Summary version of the standards, options and recommendations for nonmetastatic breast cancer (updated January 2001)

Contexte. - La Federation nationale des centres de lutte contre le cancer (FNCLCC) et les Centres regionaux de lutte contre le cancer (CRLCC), en collaboration avec des partenaires des secteurs publics (CHU, CHG), prives et certaines societes savantes ont entrepris, depuis 1993, d'elaborer des recommandations pour la pratique clinique en cancerologie: les « Standards, Options et Recommandations » (SOR). L'objectif de l'operation SOR est d'ameliorer la qualite et l'efficience des soins aux patients atteints de cancer en fournissant aux praticiens une aide a la decision facilement utilisable. La methodologie d'elaboration des SOR repose sur une revue et une analyse critique des donnees de la litterature scientifique par un groupe pluridisciplinaire d'experts, permettant de definir, sur la base du niveau de preuve scientifique et du jugement argumente des experts, des Standards, des Options et des Recommandations. Avant publication, les SOR sont revus par des experts independants. Objectifs. - Definir, sur la base d'une revue de la litterature et de l'accord d'experts, des Standards, Options et Recommandations pour la radiotherapie des patientes atteintes de cancers de sein infiltrants non metastatiques. Methodes. - Un groupe pluridisciplinaire mis en place par la FNCLCC a revu les donnees scientifiques disponibles concernant les cancers du sein infiltrants non metastatiques. Apres selection des articles, synthese des resultats et redaction des SOR, le document a ete soumis pour relecture et approbation a 148 relecteurs independants. Resultats. - Ce document presente le chapitre radiotherapie de la mise a jour 2001 du SOR paru initialement en 1996. Les modifications des Standards, Options et Recommandations apportees dans cette actualisation sont liees a de nouvelles publications. Les principales recommandations sont: il l'irradiation du sein apres chirurgie conservatrice diminue significativement le risque de recidive locale (niveau de preuve A) et l'irradiation de la paroi apres mastectomie diminue d'autant plus le risque qu'il existe des facteurs de recidive locale (niveau de preuve A). (2) Lorqu'une chirurgie conservatrice du sein est effectuee, une radiotherapie mammaire doit toujours etre delivree, a la dose minimale de 50 Gy en 25 fractions (standard, niveau de preuve A). (3) Chez les femmes de moins de 50 ans, un complement d'irradiation doit toujours etre delivre dans le lit tumoral, y compris lorsque les berges sont saines (standard, niveau de preuve B). (4) L'irradiation de la chaine mammaire interne est indiquee lorque la tumeur est interne ou centrale, en l'absence d'envahissement ganglionnaire axillaire (accord d'experts) et dans tous les cas d'envahissement ganglionnaire axillaire (standard, niveau de preuve B1). (5) L'irradiation des ganglions sus- et sous-claviculaires est indiquee en presence d'envahissement ganglionnaire axillaire (standard, niveau de preuve B1).

Six hundred seventy-six patients with ductal carcinoma in situ of the breast (DCIS) from 1971 to 1995 were included in the study. Computerized patient files were retrospectively analyzed. Clinical findings were less frequently reported to reveal DCIS after 1989. Positive mammographic findings were obtained in 87% of patients and were mainly represented by microcalcifications (79.4%). Treatment procedures were breast-conserving surgery (BCS) alone (37.5%), BCS followed by radiation (BCSR) (25.5%), or mastectomy (M) (37%). The actuarial local recurrence was 2.6% in the M group (94 months of follow-up), 14.5% in the BCS group (85,7 months of follow-up), and 7.5% in the BCSR group (78.8 months of follow-up). Predictive factors of recurrence in all patients were invaded margin status and age. In the BCS group, grade was also a predictive factor. The analysis per decade shows that the lesions currently diagnosed are less serious than those of the past. All the recurrence in patients with positive margins was in the same quadrant as the original lesion. This further emphasizes the need for clear margins.

The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of french cancer centers (FNCLCC), the 20 french cancer centers, and specialists from french public universities, general hospitals and private clinics. The main objective is the development of clinical practice guidelines to improve the quality of health care and the outcome of cancer patients. The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery.To develop clinical practice guidelines for non metastatic breast cancer patients according to the definitions of the Standards, Options and Recommendations project.Data were identified by searching Medline, web sites, and using the personal reference lists of members of the expert groups. Once the guidelines were defined, the document was submitted for review to 148 independent reviewers.This article presents the chapter radiotherapy resulting from the 2001 update of the version first published in 1996. The modified 2001 version of the standards, options and recommendations takes into account new information published. The main recommendations are: (1) Breast irradiation after conservative surgery significantly decrease the risk of local recurrence (level of evidence A) and the decrease in the risk of local recidive after chest wall irradiation is greater as the number of risk factors for local recurrence increases (level of evidence A). (2) After conservative surgery, a whole breast irradiation should be performed at a minimum dose of 50 Gy in 25 fractions (standard, level of evidence A). (3) A boost in the tumour bed should be performed in women under 50 years, even if the surgical margins are free (standard, level of evidence B). (4) Internal mammary chain irradiation is indicated for internal or central tumours in the absence of axillary lymph node involvement (expert agreement) and in the presence of lymph node involvement (standard, level of evidence B1). (5) Sub- and supra-claviculr lymph node irradiation is indicated in patients with axillary node involvement (standard, level of evidence B1).

To assess the risk of local recurrence of intraductal carcinoma of the breast with a large series and a review of literature.We present a retrospective study of 331 cases treated for intraductal carcinoma of the breast. Only patients with at least 5 years follow-up were selected. We were specially interested in recurrence risk factors. In these patients with a long follow-up; pathology was reevaluated with new investigation technique.After a median follow-up of 109 months, 40 local recurrences were observed; these lesions were invasive in 23 cases. Only one patient had recurrence after mastectomy. For the others, they had lumpectomy associated with radiotherapy in 12 cases. Histologic features, grade and therapeutic options were evaluated as risk factors of local recurrence.Follow-up after lumpectomy for intraductal carcinoma was studied. The status of tumor margins was important; irradiation appeared useful, specially in case of high grade carcinoma but further large prospective randomized studies are needed. The use of prognostic index is interesting, but there are still unanswered questions.