BREAST CANCER IN WESTERN AUSTRALIA IN 1989: III. ACCURACY OF FNA CYTOLOGY IN DIAGNOSIS

A population-based study of all cases of breast cancer diagnosed in Western Australia (WA) in 1989 revealed 701 cases of cancer in 692 women. Three hundred and ninety-six (56.5%) of these cancers had fine needle aspiration (FNA) cytology. Forty-three cases were managed non-surgically, on the basis of an FNA diagnosis and without histologic follow up. Of the cases with histological follow-up, 73% received an unequivocal diagnosis of malignancy by FNA, and abnormal cells (atypical, suspicious or malignant diagnoses) were reported in 94.2%. Of the cases, 3.2% were reported as benign and in 2.6% the samples taken were unsatisfactory. There were no false positive cytological diagnoses of malignancy. This study is the first to examine the results of FNA diagnosis of breast cancer from a medical community as a whole, rather than for individual or specialist units; the accuracy of diagnosis was similar for different pathology practices including public and private sector laboratories. Lower absolute sensitivity (the proportion of cases given an unequivocal diagnosis of malignancy) was seen in very small and very large tumours, pure duct carcinoma in situ (DCIS), and invasive lobular carcinoma. False negative rates (the proportion of cases given a benign cytological diagnosis) were very low for all laboratories (0–4.5%) and for all types of carcinoma, and the proportion of unsatisfactory samples was exceptionally low for all laboratories (0–4.5%). The overall figures for accuracy are similar to those reported from other centres in Australasia and overseas, and confirm the effective use of FNA cytology throughout the clinical and pathology community in WA.     

BREAST CANCER IN WESTERN AUSTRALIA IN 1989 V: OUTCOME AT 5 YEARS AFTER DIAGNOSIS

Background : A follow-up study was undertaken of all Western Australian women who had a new diagnosis of breast cancer during 1989. The aims were to determine survival, frequency of recurrence and quality of life (QoL) of Western Australian women 5 years after a diagnosis of breast cancer; to determine reasons for choice or rejection of reconstructive surgery in those women treated by mastectomy, and to determine if the choice of lumpectomy or mastectomy affects subsequent QoL. Methods : The vital status as at 1st June 1994 of all 692 women who had a new diagnosis of breast cancer in 1989 was ascertained by electronic linkage to official mortality registrations. A subsample of 215 survivors who had originally been treated by the nine surgeons who had managed 20 or more cases each was sent a reply-paid postal questionnaire asking about follow-up treatment since diagnosis, recurrence of disease, current QoL and attitudes to, and use of, reconstructive surgery. Results : The overall survival rate at 5 years was 80.8% (85.9% and 78.8% for Stage I and II, respectively). Cumulative mortality was 35% lower among the third of patients treated by the nine most active surgeons (14%vs 22%, P < 0.02), but this may be subject to referral bias. The subsample was representative of all surviving cases except for being an average of 2.7 years younger at diagnosis (mean ages 55.2 and 57.9 years). The response rate of the subsample to the postal questionnaire was 78%. Of women who had had a mastectomy, 40% had considered having a reconstruction, but only nine (11%) had undergone this operation. Median QoL on the Rosser scale (maximum = 1.0) was 0.9. QoL was worse for the 23% of patients with a recurrence of breast cancer. Patients treated by breast-conserving surgery showed a trend toward a better QoL compared with those treated by mastectomy. Conclusion : At 5 years after the diagnosis of breast cancer, one in five women had died and an estimated one in four of the survivors had recurrent disease. Quality of life in the remaining patients, half of whom had undergone adjuvant treatment, was very good. These are important baseline data against which to judge the impact of mammographic screening.     

THE PRESENTATION OF BREAST CANCER IN AN ORIENTAL COMMUNITY

A retrospective study was made of the presentation of breast cancer in Chinese women who were treated at the University Surgical Unit, Hong Kong, over a 20 year period (1971–90). Only 6% of patients presented with tumours less than 2 cm. Nearly half the patients presented with advanced disease. There was no tendency towards earlier presentation in the latter half of the study period. An increase in the number of patients treated for breast cancer was observed; the increase being seen mainly in postmenopausal women.     

THE COSTS OF TREATING BREAST CANCER IN AUSTRALIA AND THE IMPLICATIONS FOR BREAST CANCER SCREENING

The aim of the study was to determine if there is a relationship between the stage of breast cancer at the time of detection and the costs of treatment and to assess whether any such relationship would have an influence on the cost of a mammographic screening programme. A retrospective analysis of the stage at presentation for primary breast cancer and the treatment costs over the duration of treatment was made. Multiple regression analysis was employed, with treatment cost as the dependent variable and categorical variables to represent stage at detection. A total of 301 women whose treatment for breast cancer commenced at the Royal Brisbane Hospital participated in the study. A statistically signficiant relationship was found between the stage of disease at the time of detection and subsequent treatment costs; more advanced stages of disease incurred higher treatment costs. This relationship was robust even after taking into account the age of patients, their discharge status, and differences between patients in the duration of treatment. When the effect of earlier detection on treatment cost was assessed in relation to a breast screening programme, cost savings were estimated to be in the range of 8–36% of total screening costs. There are treatment cost savings to be gained from breast cancer screening as a result of the detection of earlier stages of disease. These treatment cost savings should be offset against the cost of a mammographic screening programme.     

PCNA IMMUNOSTAINING IN BREAST CANCER

Expression of proliferating cell nuclear antigen (PCNA) has been shown to be of prognostic value in patients with certain types of cancer. The aim of this study was to determine if the abundance of PCNA is inversely correlated with survival of patients with breast cancer. Paraffin blocks were available from 68 patients, all of whom had been followed clinically for at least 5 years. Sections from 20 patients showed no reactivity to PCNA and were excluded from the study because it was not possible to distinguish between true negatives and false negatives (those due to poor fixation of the original specimens). The PCNA index (the number of stained cancer cells as a percentage of the total number of cancer cells present) was calculated for the remaining 48 patients. Results were analysed by Wilcoxon's rank sum test (two tailed) and Pearson's correlation coefficient. There was no statistical difference between the PCNA indices of those patients dead from their disease within 5 years of diagnosis compared with those alive and without signs of breast cancer at 5 years. There was also no correlation between PCNA index and size of the cancer, involvement of axillaly lymph nodes, time to recurrence or time to death. There was, however, a significant correlation between PCNA index and histological grade (P= 0.029). It appears that PCNA staining of stored paraffin sections is of little prognostic value in patients with breast cancer.     

BREAST CANCER IN YOUNG WOMEN

Background : It is believed that cancer of the breast is more difficult to diagnose in young women and it has long been disputed whether breast cancer occurring in women aged 40 years is more aggressive than that occurring later in life. A number of reports in the literature suggest that the disease is of similar aggressiveness in the young patients and older age groups, while other reports suggest that it is more aggressive and carries a higher mortality in young women. Methods : To address these aspects of breast cancer we have undertaken a review of the cases treated at The Strathfield Breast Centre between 1989 and 1996 and compared the disease in the young and old groups with particular reference to the modes of diagnosis, the pathological staging and types of tumour and the outcomes of treatment. Results : The accuracy of ultrasound and fine needle aspiration biopsy were similar in both groups, but the false negative rate of mammography in the young patients was 15% or 50% greater than that which was observed in the older patients. The incidence of histopathological type, bilaterality, size of lesion and receptor positivity were the same in both groups. In the young group, 40% had Grade 3 tumours compared with 27% in the older group. Nineteen per cent of young patients had 4 or more lymph nodes involved while only 10% of the older patients had similar lymph node involvement. Overall 5-year survival was 79% in the older patients compared with 90% in the young patients. Conclusions : The spectrum of disease is similar in both the young and older patient and the prognosis is no worse for the young group but mammography is less effective in the diagnosis of the young patient.     

BREAST LOSS AND DELAY IN BREAST CANCER DIAGNOSIS: BEHAVIOURAL SCIENCE IN SURGICAL RESEARCH1

By the use of the methods of behavioural science, a study of women's attitudes to breast cancer and to breast surgery was carried out to provide firm data which might begin to settle the argument regarding conservative surgery for breast cancer. Conscious fears, including that of mastectomy, were found to have no significant influence on the time that a woman takes to report the presence of a breast lump to her doctor, or to commence the practice of breast self-examination. The length of delay is determined by unconscious, non-rational processes, and other factors beyond her control. Rational argument, therefore, such as that earlier diagnosis will permit more conservative surgery including partial mastectomy, zmll not influence women to present any earlier or to practise breast self-examination.     

HORMONE RECEPTORS IN MALE BREAST CANCER

Hormone receptor assays were performed on specimens of breast cancer from 19 male patients over a six year period. Ninety-four per cent were positive for oestrogen receptor, 93% for progesterone receptor and 57% for androgen receptor. Eight patients had hormonal treatment for advanced disease and five (62.5%) responded. Duration of response ranged from six months to 23 months. There appeared to be no clear relationship between hormone receptor status or quantitative receptor level and response to treatment in this small series. It is unlikely that oestrogen and progesterone receptors will be of value as discriminators because of their high incidence and it is suggested that further study of androgen receptor is indicated.     

AMINOGLUTETHIMIDE THERAPY IN ADVANCED BREAST CANCER

Aminoglutethimide inhibited adrenal steroid synthesis, as assessed by serial estimations of plasma dehydroepiandrosterone sulphate in ten patients with advanced breast cancer. There was a favourable response in seven out of the ten patients, and in four there was an objective remission using UICC criteria. Favourable responses were more common in patients who had shown similar responses to previous endrocrine therapy, especially a response to tamoxifen. Side effects were mild: two patients exhibited a drug sensitivity reaction, but neither required cessation of therapy. Adrenal suppression by aminoglutethimide is effective and well tolerated, and is therefore preferable to surgical adrenalectomy in the treatment of advanced breast cancer.     

BILATERAL BREAST CANCER IN A CHINESE MALE

The occurrence of metachronous bilateral breast cancer In a Chinese male Is described, and the difficulties in distinguishing between a second primary tumour and metastatic spread from an earlier tumour are discussed.     

VALUE OF CEA IN BREAST CANCER*

Plasma carcino-embryonic antigen (CEA) is elevated in a small percentage of patients with early breast cancer and in about 60% of patients when the disease is disseminated beyond regional lymph nodes. It is neither sufficiently sensitive or specific a test to be used for mass screening and is of limited use as a diagnostic aid. Monitoring of patients following mastectomy with serial estimations of plasma CEA is of little value in detecting disease recurrence before it becomes clinically apparent. Monitoring of CEA levels may be helpful in objectively assessing response to treatment in patients with disseminated breast cancer.     

NODAL INVOLVEMENT IN POORLY DIFFERENTIATED BREAST CANCER

The degree of nodal involvement in a consecutive series of 400 patients with invasive ductal breast cancer is presented. A positive correlation was observed between the number of metastatic nodes identified and the number of axillary nodes examined for poorly but not moderately differentiated tumours. The relevance of this observation to breast cancer trials is discussed.     

UNUSUAL PRESENTATION OF CANCER

The large bowel is the most frequent primary site for metastases in inguinal hernial sacs. We report four cases, two due to carcinoid of unknown primary, and one each due to adenocarcinoma of colon, stomach and pancreas. We recommend that all hernial sacs, particularly in the elderly, be examined microscopically.     

SCREENING FOR ABDOMINAL AORTIC ANEURYSMS IN WESTERN AUSTRALIA

A study of ultrasound screening for abdominal aortic aneurysms (AAA) was performed. During a 6 month period, 1225 men and women aged 60–80 years were screen at a variety of community venues. Screening was well received by the public and logistically simple to perform. Thirty-three AAA were detected with sizes between 30 and 81 mm. In the 60–80 year age group, the prevalence of (AAA) > 30 mm in diameter was 4.7% in men and 0.35% in women, and the prevalence of AAA > 50mm was 0.6% in men and 0.17% in women. Cigarette smoking, but not hypertension or diabetes, was found to be a significant risk factor for AAA. This study confirms that screening for AAA is feasible and yields high prevalence rates in major population centres.     

ADJUVANT SYSTEMIC THERAPY IN BREAST CANCER PART 1: ADJUVANT HORMONE THERAPY

This article reviews the use of adjuvant hormone therapy in the treatment of breast cancer and its effect on disease free survival, overall survival and local tumour control.