For much of the 20th century, the Halsted radical mastectomy was the standard surgical procedure for breast cancer of any stage. Many modifications to this basic theme use less invasive surgical procedures, sometimes accompanied by adjuvant radiation or chemotherapy. Previous reports at five and 10 years of follow-up from the National Surgical Adjuvant Breast and Bowel Project (NSABP) showed roughly equivalent results for radical mastectomy and the less invasive treatments. Fisher and colleagues report 25-year findings from this project.

The NSABP enrolled 1,079 women with node-negative breast cancer and 586 women with positive nodes. Those with negative nodes were randomized to receive either radical mastectomy (total mastectomy, plus removal of chest wall muscles and axillary contents), total mastectomy alone, or total mastectomy with irradiation. Women with positive nodes were randomized to receive either radical mastectomy or total mastectomy with irradiation. No one in this trial received adjuvant chemotherapy.

Among women with node-negative breast cancer, there were no significant differences in the breast cancer relapse rate or in overall survival rates at 25 years of follow-up between radical mastectomy and either of the less invasive treatment options. Women with positive nodes who were treated with less invasive surgery also had no significant differences in relapse-free or overall survival rates compared with women who had radical mastectomy.

The majority of the breast cancer–related adverse events (i.e., relapse, new cancer in the other breast, death) occurred early in the 25-year study. At five years of follow-up, 68 percent of the total adverse events had already occurred in the node-negative women, and 15 percent occurred after 10 years of follow-up. Women with positive nodes had 82 percent of all adverse events in the first five years, and 5 percent occurred after 10 years of follow-up.

The authors conclude that long-term follow-up corroborates earlier evidence that there is no breast cancer relapse or survival advantage for radical mastectomy compared with less invasive total mastectomy, with or without irradiation.