Skeletal Manifestations of Treatment of Breast Cancer on Premenopausal Women

With increasing use of screening mammography and more effective adjuvant systemic therapies, the majority of women diagnosed with early stage breast cancer will be long-term survivors and experience personal cures. Among the common side effects of adjuvant therapies is treatment-related bone loss, primarily as a result of estrogen deprivation. Whereas this occurs in both postmenopausal and premenopausal women, this brief review will focus on pre- or perimenopausal women when initially diagnosed with breast cancer. An important distinction is between those women who retain ovarian function despite cancer or preventative treatments and the more common situation of premenopausal women who as result of cancer treatments undergo ovarian failure or early menopause. Some women with treatment-related ovarian failure will have sufficient treatment-related bone loss to be at increased risks of subsequent nontraumatic fractures and/or osteoporosis and will be candidates for antiresorptive treatments. The noncancer treatment risk factors, screening and treatments for the management of osteopenia and osteoporosis are generally the same in postmenopausal women with and without breast cancer. However, premenopausal women with relatively rapid onset of treatment-related ovarian failure and bone loss pose several challenges. Awareness of treatment-related bone loss and risks of subsequent osteoporosis is a high priority in an ever-increasing population of breast cancer survivors.     

Management of breast cancer: basic principles

Breast cancer is the most common cancer in the UK predominately affecting women. The majority of breast cancer patients present with symptoms, but approximately 40% are diagnosed in asymptomatic women through the NHS Breast Screening Programme. Most breast cancers are now diagnosed non-operatively by triple assessment (the combination of clinical, radiological and pathological assessment) in specialist breast clinics. Breast cancer management is provided by a multidisciplinary team of breast specialists, including surgeons, radiologists, pathologists, breast care nurses and clinical/medical oncologists. Breast cancer patients now receive individualized treatment plans that may include surgery to both the breast and axilla (including breast reconstruction when appropriate), radiotherapy, endocrine treatment, chemotherapy and targeted treatments such as trastuzumab.     

Management of breast cancer: basic principles

Breast cancer is the most common cancer in the UK predominately affecting women. The majority of breast cancer patients present with symptoms, but approximately 40% are diagnosed in asymptomatic women through the NHS Breast Screening Programme. Most breast cancers are now diagnosed non-operatively by triple assessment (the combination of clinical, radiological and pathological assessment) in specialist breast clinics. Breast cancer management is provided by a multidisciplinary team of breast specialists including surgeons, radiologists, pathologists, breast care nurses and clinical/medical oncologists. Breast cancer patients now receive individualized treatment plans that may include surgery to both the breast and axilla (including breast reconstruction when appropriate), radiotherapy, endocrine treatment, chemotherapy and targeted treatments such as trastuzumab.     

Cancer early detection program based on awareness and clinical breast examination: Interim results from an urban community in Mumbai,India

Indian women with breast cancer are usually diagnosed in advanced stages leading to poor survival. Improving breast awareness and increasing access to early diagnosis and adequate treatment has been advocated for breast cancer control. We implemented a program to increase awareness on breast cancer and access to its early detection in an occupational health care scheme in Mumbai, India. Breast awareness brochures were mailed annually between June 2013 and June 2016 to a cohort of 22,500 eligible women aged 30–69 years old receiving universal health care from an occupational health care scheme comprising of primary health centres and a referral secondary care hospital in Mumbai. Women with suspected breast cancers were provided with diagnostic investigations and treatment. Socio-demographic information and tumour characteristics were compared between the breast awareness pre-intervention period (Jan 2005–May 2013) and the breast awareness intervention period after four rounds of mailers (June 2013–June 2016). The proportion of women with early tumours and axillary lymph node negative cancers increased from 74% to 81% and 46% to 53% respectively, between the two periods. While the proportion of patients receiving breast conserving surgery increased from 39% to 51%, the proportion receiving chemotherapy decreased from 84% to 56%. Interim results following efforts to improve breast awareness and access to care in a cohort of women in an occupational health care scheme indicate early detection and more conservative treatment of breast cancers. Creating awareness and improving access to care may result in cancer down-staging.     

Postmenopausal Breast Cancer,Aromatase Inhibitors,and Bone Health: What the Surgeon Should Know

Breast cancer, as the most common malignancy in women, remains a major public health issue despite countless advances across decades. Endocrine therapy is the cornerstone of treatment of the hormone-sensitive subtype of breast cancer. The use of aromatase inhibitors (AIs) in the postmenopausal women has extended the survival beyond that of Tamoxifen, but harbors a subset of side effects, most notably accelerated bone loss. This, however, does not occur in all women undergoing treatment. It is vital to identify susceptible patients early, to limit such events, employ early treatment thereof, or alter drug therapy. International trials on AIs, predominantly performed in North American and European females, provide little information on what to expect in women in developing countries. Here, surgeons often prescribe and manage endocrine therapy. The prescribing surgeon should be aware of the adverse effect of the endocrine therapy and be able to attend to side effects. This review highlights clinical and biochemical factors associated with decrease in bone mineral density in an, as yet, unidentified subgroup of postmenopausal women. In the era of personalized medical care, appropriate management of bone health by surgeons based on these factors becomes increasingly important.     

Supportive and palliative care for metastatic breast cancer: Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced-stage disease. While cure is not a realistic outcome, site-specific interventions, supportive care, and palliative care can achieve meaningful outcomes and improve quality of life.As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three resource-stratified tables: health system resource allocations, resource allocations for organ-based metastatic breast cancer, and resource allocations for palliative care. These tables illustrate how health systems can provide supportive and palliative care services for patients at a basic level of available resources, and incrementally add services as more resources become available.The health systems table includes health professional education, patient and family education, palliative care models, and diagnostic testing. The metastatic disease management table provides recommendations for supportive care for bone, brain, liver, lung, and skin metastases as well as bowel obstruction. The third table includes the palliative care recommendations: pain management, and psychosocial and spiritual aspects of care.The panel considered pain management a priority at a basic level of resource allocation and emphasized the need for morphine to be easily available in LMICs. Regular pain assessments and the proper use of pharmacologic and non-pharmacologic interventions are recommended. Basic-level resources for psychosocial and spiritual aspects of care include health professional and patient and family education, as well as patient support, including community-based peer support.     

Supportive care during treatment for breast cancer: Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer patients may have unmet supportive care needs during treatment, including symptom management of treatment-related toxicities, and educational, psychosocial, and spiritual needs. Delivery of supportive care is often a low priority in low- and middle-income settings, and is also dependent on resources available.This consensus statement describes twelve key recommendations for supportive care during treatment in low- and middle-income countries, identified by an expert international panel as part of the 5th Breast Health Global Initiative (BHGI) Global Summit for Supportive Care, which was held in October 2012, in Vienna, Austria. Panel recommendations are presented in a 4-tier resource-stratified table to illustrate how health systems can provide supportive care services during treatment to breast cancer patients, starting at a basic level of resource allocation and incrementally adding program resources as they become available. These recommendations include: health professional and patient and family education; management of treatment related toxicities, management of treatment-related symptoms of fatigue, insomnia and non-specific pain, and management of psychosocial and spiritual issues related to breast cancer treatment.Establishing supportive care during breast cancer treatment will help ensure that breast cancer patients receive comprehensive care that can help 1) improve adherence to treatment recommendations, 2) manage treatment-related toxicities and other treatment related symptoms, and 3) address the psychosocial and spiritual aspects of breast cancer and breast cancer treatments.     

Bone loss in patients with breast or prostate cancer

Cancers of the breast and prostate are very common in the general population, with breast cancer accounting worldwide for 23% of cancer cases in women and prostate cancer accounting for 12% of cases in men. During the past decade, the survival rates of patients with estrogen-dependent breast cancer and testoster-one-dependent prostate cancer have improved. This improvement has been possible thanks to the introduction of hormone treatments that suppress the synthesis or antagonize the actions of gonadal steroids. However, estrogen and testosterone deficiencies are associated with excessive bone resorption that translates into damage of the bone microarchitecture, loss of bone mineral density, and predisposition to osteoporosis and fractures. Herein, we review the mechanisms of bone loss in breast and prostate cancer survivors, their clinical implications, and different available therapeutic modalities that may help to correct the damage of bone and prevent the development of fractures.     

The quality of early-stage breast cancer care

OBJECTIVE: To assess whether recent practice has improved, the authors created detailed, evidence-based guidelines and assessed the quality of early-stage breast cancer care at four hospitals in the metropolitan New York area. SUMMARY BACKGROUND DATA: Adjuvant treatments for early-stage breast cancer have been shown to improve health and longevity. However, reports from the 1980s showed marked underuse of these therapies. METHODS: All 723 women with early-stage breast cancer who had a definitive surgical procedure at four participating hospitals in the Mount Sinai-NYU Health System between April 1994 and August 1996 were included. Inpatient and outpatient records were abstracted. RESULTS: Fifty-nine percent of women underwent breast-conserving surgery, of whom 81% received radiation therapy. Hospital-specific radiation therapy rates varied from 69% to 87%. Seventy-eight percent of women with stage 1B or greater cancer received systemic treatment, with hospital-specific rates varying from 71% to 86%. Between 18% and 33% of women who could have benefited from local or systemic adjuvant treatments did not receive them. The risk of not getting a beneficial adjuvant treatment varied more than twofold by the hospital where the breast cancer surgery was performed. CONCLUSIONS: The hospital where breast cancer surgery is performed is associated with the likelihood that women receive effective local and systemic adjuvant treatments. Surgeons and members of hospital quality improvement programs should encourage multidisciplinary approaches to breast cancer care.     

Factors associated with breast MRI use among women with a family history of breast cancer

Although annual breast magnetic resonance imaging (MRI) is recommended for women at high risk for breast cancer as an adjunct to screening mammography, breast MRI use remains low. We examined factors associated with breast MRI use in a cohort of women with a family history of breast cancer but no personal cancer history. Study participants came from the Sister Study cohort, a nationwide, prospective study of women with at least 1 sister who had been diagnosed with breast cancer but who themselves had not ever had breast cancer (n = 17 894). Participants were surveyed on breast cancer beliefs, cancer worry, breast MRI use, provider communication, and genetic counseling and testing. Logistic regression was used to assess factors associated with having a breast MRI overall and for those at high risk. Breast MRI was reported by 16.1% and was more common among younger women and those with higher incomes. After adjustment for demographics, ever use of breast MRI was associated with actual and perceived risk. Odds ratios (OR) were 12.29 (95% CI, 8.85‐17.06), 2.48 (95% CI, 2.27‐2.71), and 2.50 (95% CI, 2.09‐2.99) for positive BRCA1/2 test, lifetime breast cancer risk ≥ 20%, and being told by a health care provider of higher risk, respectively. Women who believed they had much higher risk than others or had higher level of worry were twice as likely to have had breast MRI; OR = 2.23 (95% CI, 1.82‐2.75) and OR = 1.76 (95% CI, 1.52‐2.04). Patterns were similar among women at high risk. Breast cancer risk, provider communication, and personal beliefs were determinants of breast MRI use. To support shared decisions about the use of breast MRI, women could benefit from improved understanding of the chances of getting breast cancer and increased quality of provider communications.     

Surgical techniques in breast cancer: an overview

Breast cancer is the most common female cancer and its incidence continues to increase. Ongoing advances in adjuvant treatments have resulted in declining mortality rates with increasing numbers of women surviving their breast cancer diagnosis. While the primary outcome of surgery remains oncological efficacy, the contemporary breast surgeon must consider the long-term aesthetic outcome of the procedure and the inevitable impact on body image and self-esteem. There has been a paradigm shift in breast surgery in the UK over the last 20 years with the widespread provision of oncoplastic breast surgery techniques now representing the standard of care. As the role of breast conserving surgery has been extended by therapeutic mammoplasty and the use of neoadjuvant treatments, mastectomy rates continue to decline. The widespread introduction of sentinel node biopsy has fostered an increasingly conservative approach to axillary surgery. Nationally, rates of immediate breast reconstruction following skin-sparing mastectomy continue to rise. Yet the National Mastectomy and Breast Reconstruction Audit highlighted the disparities in care and wide variation in practice that still exists in the UK. Whilst breast reconstruction is widely practiced, the adoption of the Oncoplastic Breast Surgery Best Practice Guidelines and engagement with long-term follow-up studies focusing on patient-reported outcome measures will hopefully result in a consistently high standard of care.     

Surgical techniques in breast cancer: an overview

Breast cancer is the most common female cancer and its incidence continues to increase. Ongoing advances in adjuvant treatments have resulted in declining mortality rates with increasing numbers of women surviving their breast cancer diagnosis. Whilst the primary outcome of surgery remains oncological efficacy, the contemporary breast surgeon must consider the long-term aesthetic outcome of the procedure and the inevitable impact on body image and self-esteem.There has been a paradigm shift in breast surgery in the UK over the last 20 years with oncoplastic breast surgery (OPBS) techniques now representing the standard of care. As the role of breast conserving surgery (BCS) has been extended by therapeutic mammoplasty and the use of neoadjuvant treatments, mastectomy rates continue to decline. The introduction of sentinel node biopsy (SNB) has fostered an increasingly conservative approach to axillary surgery. Nationally, rates of immediate breast reconstruction (IBR) following skin-sparing Mastectomy (SSM) continue to rise. Yet the National Mastectomy and Breast Reconstruction Audit (NMBRA) highlighted the disparities in care and wide variation in practice that still exists in the UK. Whilst breast reconstruction is widely practised, the adoption of the Oncoplastic Breast Surgery Best Practice Guidelines and engagement with long-term follow-up studies focusing on patient reported outcome measures (PROMs) will hopefully result in a consistently high standard of care.     

Patterns of seeking medical care among Egyptian breast cancer patients: relationship to late-stage presentation

Breast cancer is the most common cancer among Egyptian women, accounting for 37.6% of female tumors, and is often diagnosed at later stages. The objective of this study was to investigate breast cancer patient navigation through the health care system in the Nile Delta. Interviews were conducted with 163 newly diagnosed breast cancer patients at the Tanta Cancer Center (TCC), the major cancer center of the region. Patients described their medical care pathway from the initial symptom experienced until their arrival at TCC. Patients whose initial contact was with a general surgeon (OR: 7.6, 95% CI: 2.1, 27.6), primary care provider (OR: 12.2, 95% CI: 2.9, 51.0), or gynecologist (OR: 8.6, 95% CI: 1.4, 53.4) were significantly more likely to experience a delay in reaching the TCC as compared to those visiting a surgical oncologist. Overcoming health care system and patient navigation barriers in developing countries may reduce the time for breast cancer patients to reach a cancer center for early management.     

The importance of survivors and partners in improving breast cancer outcomes in Uganda

In limited-resource countries, cancer kills more people annually than AIDS, tuberculosis and malaria combined. Programs targeting early detection and treatment of cancer are virtually non-existent due to insufficient funding and attention given to this emerging health challenge. Breast cancer is the most common cancer in women worldwide and is also the leading cause of cancer-related death in females. In developing countries such as Uganda, breast cancer incidence is increasing and typically presents at an advanced stage of disease, for which treatment options are limited. Inadequate knowledge and understanding of the disease, social stigma, and barriers to care all contribute to a poorer prognosis. There are many challenges to reducing breast cancer incidence and mortality globally; however, there is evidence to suggest that advocacy and education, in particular through the efforts of breast cancer survivors and their partners, can play a critical role in improving overall outcomes in limited-resource countries.     

Diet and Breast Cancer: Can Dietary Factors Influence Survival?

Breast cancer accounts for over one third of invasive cancers in women. Earlier detection and improved initial treatments have resulted in an increasing number of women who have completed standard treatments but who remain at risk for breast cancer recurrence or early death. Epidemiological studies have linked diet composition with prognosis, and many women attempt to modify their diets and improve nutritional status following diagnosis. The hypothesis that dietary factors may reduce risk for secondary cancer events and increase survival in this population is currently under study in two large randomized clinical trials: the Women's Intervention Nutrition Study (WINS) and the Women's Healthy Eating and Living (WHEL) Study. The WHEL Study is testing the effect of a diet high in vegetables, fruit, and fiber, and low in fat, on disease-free survival in women with early stage breast cancer. Hypothesized mechanisms include effects of diet modification on gonadal hormones, retinoid-like activities of carotenoids, and other protective effects of biologically active dietary constituents.     

Heel ultrasound can assess maintenance of bone mass in women with breast cancer

Postmenopausal women with early stage breast cancer are at increased risk for bone loss and fractures. Bisphosphonates can prevent bone loss, but little data are available on changes in bone mass assessed by heel quantitative ultrasound (QUS). Our objectives were to determine if (1) heel QUS would provide a reliable and accessible method for evaluation of changes in bone mass in women with breast cancer when compared with the current standard of bone mass measurement, dual-energy X-ray absorptiometry (DXA) and (2) oral risedronate could affect these changes. Eighty-six newly postmenopausal (up to 8 yr) women with nonmetastatic breast cancer were randomized to risedronate, 35 mg once weekly or placebo. Outcomes were changes in heel QUS bone mass measurements and conventional DXA-derived bone mineral density (BMD). Over 2 yr, bone mass assessed by heel QUS remained stable in women on risedronate, whereas women on placebo had a 5.2% decrease (p ≤ 0.05) in heel QUS bone mass. Both total hip BMD and femoral neck BMD assessed by DXA decreased by 1.6% (p ≤ 0.05) in the placebo group and remained stable with risedronate. Spine BMD remained stable in both groups. Heel QUS was moderately associated with BMD measured by DXA at the total hip (r=0.50), femoral neck (r=0.40), and spine (r=0.46) at baseline (all p ≤ 0.001). In conclusion, risedronate helps to maintain skeletal integrity as assessed by heel QUS for women with early stage breast cancer. Heel QUS is associated with DXA-derived BMD at other major axial sites and may be used to follow skeletal health and bone mass changes in these women.     

A Community‐Oriented Approach to Breast Cancer in a Low‐Resource Setting: Improving Awareness,Early Detection and Treatment of Breast Cancer in Tajikistan

Breast cancer is one of the most common cancers and causes of death in females in Tajikistan; yet less than half of the adult women in Tajikistan have heard of breast cancer. Limited access to health care contributes to late stage presentation. We developed a public–private partnership to implement a breast cancer awareness intervention in a low‐resource community in Khorog, Tajikistan. We trained local health professionals in clinical breast care and conducted a breast cancer screening and treatment program. The partnership involved visiting USA‐based health professionals working alongside local health care providers (HCP) in the continuum of breast care—from education to the diagnostic evaluation and management of detected breast abnormalities. Patient data were collected using a web‐based program (VirtualDoc). Twenty‐four HCP received didactic and clinical breast examination training. 441 women underwent clinical breast evaluation. 74 (17%) had abnormal exams and underwent additional diagnostic procedures. We identified six (1.4%) cases of breast cancer (all locally advanced) and two women had benign fibroadenomas. All women with cancer underwent modified radical mastectomy, while the fibroadenomas were treated by cosmetically appropriate lumpectomy. Five of six subjects with cancer were previously aware of their breast lump and three had recently seen a family medicine (FM) doctor. Health systems assessment revealed availability of diagnostic equipment but lack of well‐trained operators and clinician interpreters. We were successful in integrating clinical breast exams into the routine care of female patients by local FM doctors and in the process, achieved a better understanding of existing risk factors and barriers to breast cancer care. This public–private partnership, leveraging the technical expertise of visiting health professionals, demonstrates how a focused onsite training and awareness program can provide sustained improvements in breast care in a low‐resource environment.     

唑来膦酸对乳腺癌治疗相关骨流失保护作用的研究进展

乳腺癌是女性最为常见的恶性肿瘤之一。化疗及内分泌治疗显著改善了早期乳腺癌患者的预后,然而肿瘤治疗带来的骨流失问题值得关注。内分泌治疗通过降低雌激素水平发挥治疗作用;化疗可导致绝经前女性卵巢功能衰竭,同样使体内雌激素水平显著下降。而低雌激素水平减少骨生成、增加骨吸收,使骨质流失和骨质疏松症的发病率增加、骨折风险升高。第三代双膦酸盐唑来膦酸是一种特异性地作用于骨的二磷酸化合物,已被证实通过抑制破骨细胞活性和诱导破骨细胞凋亡来抑制骨吸收。本文将对唑来膦酸防治女性乳腺癌患者相关骨流失的临床研究进展进行综述。     

Coping With a Diagnosis of Breast Cancer-Literature Review and Implications for Developing Countries

Abstract:  Breast cancer is the most common cancer affecting women worldwide. Women are at an increased risk of developing both physical and psychological morbidity after diagnosis; however, many use different strategies to cope with the disease. The aim of this article is to review the available literature on the impact of breast cancer diagnoses and the strategies used by women to cope with this disease. The implications of these emerging findings are extrapolated within the context of health services provided in developing countries. Electronic databases were used to search the relevant literature. The findings showed that women who were diagnosed with breast cancer are at risk of developing several psychological morbidities such as depression, anxiety, fatigue, negative thoughts, suicidal thoughts, fear of dying, sense of aloneness, sexual and body images problems, as well as an overall decrease in the quality of life. Several strategies are used by women with breast cancer to cope with the disease, including positive cognitive restructuring, wishful thinking, emotional expression, disease acceptance, increased religious practice, family and social support, and yoga and exercise. Breast cancer diagnoses have been associated with several devastating psychological consequences; however, many women have used different coping strategies to adjust their lives accordingly. Healthcare professionals in developing countries, who work with women with breast cancer, should be aware of the different coping mechanisms that women use when diagnosed with cancer. Integrating a coping strategy into the treatment regimen would constitute an important milestone in the palliative care of patients with breast cancer.