M.H. Galea

The Nottingham prognostic index in primary breast cancer

SummaryIn 1982 we constructed a prognostic index for patients with primary, operable breast cancer. This index was based on a retrospective analysis of 9 factors in 387 patients. Only 3 of the factors (tumour size, stage of disease, and tumour grade) remained significant on multivariate analysis. The index was subsequently validated in a prospective study of 320 patients. We now present the results of applying this prognostic index to all of the first 1,629 patients in our series of operable breast cancer up to the age of 70. We have used the index to define three subsets of patients with different chances of dying from breast cancer: 1) good prognosis, comprising 29% of patients with 80% 15-year survival; 2) moderate prognosis, 54% of patients with 42% 15-year survival; 3) poor prognosis, 17% of patients with 13% 15-year survival. The 15-year survival of an age-matched female population was 83%.

Safe selection criteria for breast conservation without radical excision in primary operable invasive breast cancer

In a previous series from this unit of 263 women with primary operable breast cancer treated by macroscopic lumpectomy and breast irradiation, local recurrence was high. An audit at a median follow up of 36 months showed 56 (21%) ipsilateral breast recurrences. Eighteen of these recurrences were aggressive and uncontrolled. Multivariate analysis shows patient age, lymphovascular invasion, tumour size and nodal status to be predictive of local recurrence (Locker AP, et al., Br J Surgery 1989, 76, 890-894). New selection criteria for breast conservation were defined based on these data and also on securing an adequate clear margin of excision. In a subsequent prospective series of 275 women fulfilling these criteria, 6 women (2.2%) developed ipsilateral breast recurrence at the same median follow up of 36 months. In none was this uncontrolled and aggressive. Breast conservation, without radical excision, is safe as long as the selection criteria described are followed.

A comparison of the characteristics and prognosis of screen detected and symptomatic breast cancers

Breast screening aims to save years of life for women who would otherwise have died prematurely from breast cancer. In order to achieve this it needs to detect breast tumours that are of smaller size, better grade and type and earlier stage than those presenting symptomatically. We have compared the tumours detected in our symptomatic practice with those detected at breast screening over the last 5 years.

Comment on ‘Predicting recurrence in axillary node negative breast cancer patients’, by Rosner and Lane

We read with interest the publication by Rosner and Lane (Breast Cancer Res Treat 25: 127-139, 1993), attempting to identify low and high risk node negative breast cancer patients using validated clinical and pathological prognostic factors. While we would largely agree with their findings, no reference is made to the Nottingham Prognostic Index (NPI) which has recently been validated in this journal (Breast Cancer Res Treat 22: 207-219, 1992) and which for practical purposes divides node negative patients into two such groups. The index combines in an appropriately weighted (risk contribution derived from multivariate analyses) and easily calculated way, tumour size, histological grade, and lymph node stage. The higher the index scores the worse the prognosis. Both for prognostic information and for planning of adjuvant treatment, we have found subdivision of scores into three groups (Good, Moderate and Poor) to be useful. All except 6% of patients in the Good Prognostic Group (GPG) are node negative, with tumours < 2 cms and of either good or moderate histological grade; this accounts for 43% of node negative patients in our symptomatic series. Patients in this group have an overall survival out at 10 years on the order of 86%. This is not much less than survival over the same period for age matched women without breast cancer (Fig. 1). Few women (< 10%) in this group will die from their disease. The very small potential benefit for the group as a whole means that the morbidity of cytotoxic therapy is unacceptable. Hormonal agents too, such as tamoxifen, although generally regarded as safe, are not without side effects: also women in the GPG have tumours