Breast Cancer Local Therapy: What Is Its Effect on Mortality?

Until recently, the concept of biological predeterminism appeared pre-eminent and a worthy successor to the Halstedian doctrine of centrifugal spread of cancer. However, evidence has now emerged from clinical trials to cast doubt on the universal application of this concept to breast tumors. Prevention of local recurrence can save lives, local control does matter, and rates of local recurrence should be minimized in the first 5 years. In up to one quarter of cases of local recurrence the locally recurring disease will be a determinant and not simply a marker of risk for distant relapse and death. Both types of local recurrence are manifestations of the same biological processes and reflect intrinsic behavior of the tumor. This principle applies to reduction in local relapse from both adjuvant radiotherapy and surgical modalities.     

Is Tamoxifen Alone Adequate Therapy in Very Young Chinese Women with Operable Breast Cancer?

Breast cancer occurs earlier in Chinese women than in Caucasian women. We have compared the clinicopathologic characteristics and prognosis in very young and older premenopausal women with breast cancer in south China. We separated 905 consecutive premenopausal patients with first diagnosis of breast cancer, surgically treated at the Sun Yat-sen University Cancer Center from October 2003 to December 2006, into a very young group (189 [13.7%]; <35 years old) and an older group (716 [52.0%]; 35-57 years old). Approximately, 90% of patients received adjuvant chemotherapy and hormonal therapy with tamoxifen for hormone-receptor (HR)-positive breast cancer. We retrospectively compared the clinicopathologic factors and survival rates of these two groups. The 3-year disease-free survival rate (78.0% versus 89.1%, p < 0.001) was poorer in the very young group, and 3-year overall survival rate (94.3% versus. 96.8%, p = 0.10) was similar. Moreover, the 3-year overall survival rate (p = 0.020) and disease-free survival rate (p < 0.001) were significantly poorer in HR-positive patients in the very young group whereas there was no significant difference in outcomes between the HR-negative groups. In China, age younger than 35 years is an independent predictor of breast cancer recurrence. In very young women with HR-positive breast cancer, chemotherapy plus tamoxifen alone may not be adequate standard treatment.     

Ipsilateral Breast Tumor Recurrence: Is There Any Evidence for Benefit of Further Systemic Therapy?

Abstract:  To date, there are no standard guidelines for treating patients with ipsilateral breast tumor recurrence (IBTR). Current practice is to resect the recurrence with a radical intent followed possibly by radiotherapy if the patient has not received this before, but the role of further adjuvant medical (hormone or chemotherapy) therapy remains undefined. Currently Phase III trials are underway to answer this question. In this review, we will focus on published data relating to IBTR and discuss recent trials. The results from the Phase III trials will not be available for sometime. At the time of IBTR, it is reasonable to change the endocrine therapy with indirect evidence from sequencing of impact on outcome. There is currently no conclusive evidence to suggest that further adjuvant chemotherapy post loco-regional recurrence impacts on survival, though the use of noncross-resistant chemotherapy drugs may make sense in those at highest risk. Biopsy at IBTR is helpful to distinguish whether it is a true recurrence or a new primary tumor and receptor phenotyping may be helpful for HER2. Future trials in IBTR need to address the following issues: to be able to distinguish between true recurrence and new primary (consensus required on definitions); pathologic processing relating to margins needs to be standardized (1 or 5 mm wide specimens); documentation of the pattern of IBTR in relation to each histopathologic subtype and methods used for pathologic examination by centers. Regional nodal recurrence including supraclavicular node recurrence is not dealt with in this review.     

Is Pregnancy After Breast Cancer Safe?

Abstract: The impact of treatment on subsequent fertility and the safety of childbearing are major complicating factors for young women diagnosed with breast cancer. As national data indicate women are postponing first pregnancy to older ages; therefore, many young patients are seeking clinical guidance regarding the safety of conception and treatment options that may not prevent subsequent pregnancy. Newly developed chemotherapy protocols of brief duration have improved life expectancy enabling some women to consider childbearing. This study was conducted to compare prognosis among breast cancer patients with and without a subsequent pregnancy. Medical record review of female members of a Northern California prepaid health care plan enabled the identification of 107 women with one or more subsequent pregnancies and 344 cases without a pregnancy, who were diagnosed between 1968 and 1995. Sets were matched on age, year and stage at diagnosis, months of survival and recurrence status at conception. Among the matched sets, neither risk of recurrence nor death differed significantly by subsequent pregnancy history during an average 12 years of follow‐up (adjusted hazard ratio [HR] recurrence: 1.2 [0.8, 2.0]; adjusted HR death: 1.0 [0.6, 1.9]). Women interested in preserving their fertility and considering pregnancy are a self‐selected population; therefore, to reduce potential bias, cases were matched on recurrence status at time of conception. Although the number of cases was limited, subgroup analyzes indicated a small, nonsignificant adverse effect among women who conceived within 12 months of diagnosis. This analysis of carefully matched cases provides reassurance that long‐term prognosis was not adversely affected by subsequent pregnancy.     

Chemotherapy in Old Women with Breast Cancer: Is Age Still a Predictor for Under Treatment?

Breast cancer affects mostly older women but there are no guidelines especially devoted to adjuvant chemotherapy for this population. In this context, this study was carried out in a population‐based cohort of French elderly women with breast cancer, to check adherence to the existing national guidelines according to the women's age, taking into account the evolution of the situation over time for women requiring chemotherapy. Between October 2006 and December 2008, all consecutive women included in the French Health registry for a biopsy‐proven primary nonmetastatic breast cancer, aged 65–80 years at diagnosis, and living in South Eastern France, were asked to participate in a cohort study. Medical information was collected from physicians. The study population was restricted to the 223 women who were recommended adjuvant chemotherapy according to national guidelines. Those who received chemotherapy were compared to those who did not receive this treatment. Among these 223 women 55% had received chemotherapy. Only three women refused the treatment. Less than 8% have had a geriatric assessment before treatment decision and only two were proposed to participate in a clinical trial. After adjustment for comorbidity score, tumor characteristics, socio‐demographic characteristics, and year of diagnosis, increasing patient age was independently associated with decreased guideline concordance for adjuvant chemotherapy. Women aged 75–80 years received chemotherapy more than four times less often than women aged 65–74 years. However, the percentage of women who received chemotherapy increased from 33% to 58% between 2006 and 2008, in parallel with the setting up of Onco‐Geriatric Coordination Units in the area. In France, chronological age remains a barrier to receive chemotherapy for older breast cancer women but the establishment of a formal collaboration between oncologists and geriatricians seems to be an effective way to improve care delivery in this population.     

Which Eligible Breast Conservation Patients Choose Mastectomy in the Setting of Newly Diagnosed Breast Cancer?

Purpose  

Breast conserving therapy (BCT) and mastectomy offer equivalent survival for women with newly diagnosed breast cancer (BrCa). Despite this, many women eligible for BCT elect mastectomy. Herein, we identify factors associated with choosing ipsilateral mastectomy instead of BCT when mastectomy is not required.     

Does Local Therapy Affect Survival Rates in Breast Cancer?

Background: The goal of this study was to challenge the hypothesis that local recurrence of breast cancer does not affect survival rates, by determining whether survival rates differ for conservative and radical surgical policies. Methods: This study used prospective long-term follow-up monitoring of two contemporaneous groups of patients, within a single unit, who were treated identically except for the one variable of local treatment policy, i.e., conservative or radical. A total of 451 patients with operable breast cancer were chosen from 567 consecutive patients with breast cancer who were treated between 1970 and 1979 in the University Department of Surgery. The rate of survival 132 months after treatment was used as an outcome measure.Results: Two hundred forty-one patients were treated using a conservative approach and 210 were treated using a radical approach. At 132 months, the survival rate (58% vs. 42%) and median survival time (>132 vs. 100 months) were significantly improved for the radically treated group (P < .01). The treatment groups were comparable in terms of age, menopausal status, tumor size, histologic grading, and Nottingham Prognostic Index values. The advantage of the radical policy persisted when examined in relation to each of these prognostic factors.Conclusions: Use of radical local treatment yielded a highly significant survival benefit (comparable to that obtained with adjuvant therapy), compared with a conservative approach. This was related to a reduced locoregional recurrence rate and provides evidence that local therapy influences long-term outcomes for patients with breast cancer. High-quality locoregional control should be emphasized, as is systemic therapy, in management policies. Assessment of surgical techniques, particularly in relation to locoregional recurrence rates, should be included in all studies in which surgery is a component of therapy.     

Is Breast Augmentation Using Hyaluronic Acid Safe?

Macrolane™, a compound composed of hyaluronic acid, is the newest product to be marketed for breast augmentation. Like many previous breast augmentation products, Macrolane has been authorised for use with very little published scientific data on its safety and efficacy in breast augmentation. This article reviews the evidence available on the safety of using hyaluronic acid and raises concerns with regard to its use as a product for breast augmentation, the technique recommended for its use, and the authorisation process for new implantable medical devices. It is strongly recommended that clinicians review the lack of data on Macrolane before offering it as a treatment option to patients.     

Immunomodulation via Chemotherapy and Targeted Therapy: A New Paradigm in Breast Cancer Therapy?

Cytotoxic chemotherapy in the treatment of tumors has traditionally been thought to be immunosuppressive. Increasing evidence suggests the contrary and has introduced the concept of ‘immunogenic’ chemotherapy or, in other words, the concept that the innate and adaptive immune systems are critical in determining the long-term efficacy of some cytotoxic-based (and radiotherapy-based) regimens. The underlying mechanisms how these therapies can stimulate an antitumor immune response have been demonstrated recently. In this article, we review the background of this new paradigm and how combinations of traditional agents with the new immunotherapeutic therapies may significantly advance our treatment of breast cancer.