The participation of women with breast cancer in choosing their treatment: a right as yet to be gained

The purpose of this study was to identify how women with breast cancer perceive themselves as subjects in the process of making decisions on their own treatment. Two objectives were pursued: (a) to identify social and political determinants that, by affecting the socialization process of these women, might have influenced them in adopting a style of participation, and (b) to understand the meaning of such participation, as it was perceived by these women at the time they decided on their treatment options. The theoretical-methodological support adopted was that of Symbolic interactionism. The population sample included nine women with breast cancer. Semi-structured interviews allowed data to be gathered, and led to collecting further field notes and data from medical records. The hermeneutic dialectic method was employed as a compass for data interpretation, which made it possible to identify two broad theme units: 'construction of the female identity' and 'style of participation when choosing one's own treatment'. By means of these units it was possible to grasp what it meant for these women to deal with the issue of limits and, therefore, of ethics. In their view, they did not participate in the decision-making process, being regarded as unqualified to decide on the fate of their own bodies and lives. They were thus seen as obedient subjects in relation to medical decisions that are based on the principle of beneficence, where health care delivery is dependent on hierarchical social relationships and power structures are present between classes, genders, and levels of knowledge.     

Breast-conserving surgery in early-stage breast cancer (indications, local recurrences, survival, cosmetic results)

INTRODUCTION: Breast cancer is an extremely actual problem in modern medicine and surgery in particular. Constantly growing frequency, younger age of the newly diagnosed patients, severe psychological collapse of the patients and serious impairment of quality of life are only some of the factors determining actuality of the problem. AIM: The aim of the present survey is to make a retrospective comparative clinical analysis of the results obtained after breast-conserving surgery and simple mastectomy in terms of 5- and 10-year survival, local recurrences and cosmetic outcome. PATIENTS AND METHODS: Over a 19-year period, 269 breast cancer patients were treated in the Clinic. Breast-conserving surgery plus axillary lymph node dissection in levels I, II and III was performed in 66.17% of the patients. In 33.83% of the patients ablation of the mammary gland (simple mastectomy) plus axillary lymph node dissection was done. In both groups adjuvant radiation therapy was performed and patients with positive axillary lymph nodes were further subjected to chemotherapy. Adjuvant hormone therapy with anti-estrogen drugs was administered in estrogen positive patients. RESULTS: Study of the late (5- and 10-year) results showed that in complex treatment the recurrence rate in patients subjected to breast-conserving surgery (BCS) was 4.00% and in those treated by simple mastectomy (SM)--2.99%. The 5-year survival was 90.10% for the patients undergoing BCS and 88.89% for those treated by SM. The 10-year survival was 80.56% for the patients treated by BCS and 77.14% for those subjected to SM. CONCLUSIONS: Breast-conserving surgery is indicated in all patients in stage I and II of the disease and tumor measured up to 3.5 cm regardless of the axillary lymph nodes status. There is no statistically significant difference in the survival rate between the two compared groups and cosmetic results are much better in the patients subjected to breast-conserving surgery. When complex treatment is accomplished breast-conserving operations provide recurrence rate equal to that in simple mastectomy. Unfavorable prognostic factors for recurrence are younger age, bigger lump size, greater number of positive lymph nodes and estrogen/progesterone negative status.     

Multi-detector CT screening for lung cancer is still to be discouraged for the time being

Lung cancer is an important public health problem with almost no improvement in survival over the past decades. Although observational studies demonstrate that low-dose multi-detector spiral-CT screening is able to detect lung cancer in an early stage in 55-85% of all cancer cases detected, and that 5- and even 10-year survival rates close to 90% can be achieved, these studies do not answer the question whether CT screening is advisable. Excellent survival rates in a few individuals do not necessarily indicate that there is a lung cancer-specific reduction in mortality, since observational studies are subject to several biases: lead time bias, over-diagnosis bias, and length time bias. Therefore, there is a strong worldwide recommendation from various professional organisations not to adopt CT screening for lung cancer on a wide scale, but to await the results from large randomised studies such as the US 'National lung screening trial' and the Dutch-Belgian-Danish 'Netherlands-Louvain lung cancer screening study' (NELSON), which will provide more clarity as to the effectiveness and cost-effectiveness and possible negative effects of CT screening for lung cancer.     

Screening for breast cancer in Catalonia: Which policy is to be preferred?

Background: the effects and costs of different policies forbreast cancer screening in Catalonia (Spain) were analysed,to give a basis for setting priorities and deciding on the introductionof a screening programme. Methods: the MISCAN (MIcrosimulationSCreening ANalysis) model of the natural history of breast cancerwas used. The epidemiology of breast cancer in Catalonia andthe demography of the Catalan population was taken into accountas well as the results on mortality reduction from a Swedishoverview of breast cancer screening trials. Results: the reductionin breast cancer mortality in the total female population dueto a screening programme for the age group 50–64 yearswould be 16, 12 and 9%, with screening intervals of one, twoand three years respectively. The cost-effectiveness ratios(CE ratios) for these scenarios were 924,000, 730,000 and 719,000pesetas (P_t) per life-year gained respectively (5% discounting).The most cost-effective screening scenario is the one in whichwomen aged 50–69 years are screened with an interval ofthree years with a mortality reduction of approximately 12%in the total female population (CE ratio = 694,000 P_t). Screeninguntil the age of 69 years (two year interval) was almost ascost-effective as screening the age group 50–64 yearswith a two year interval, with a reduction in breast cancermortality of 15%. Extension to under the age of 50 years resultedin diverging results depending on the assumptions for improvementin prognosis for younger women (40–49 years). Conclusion:if the extension of a two yearly screening programme for womenaged 50–64 years is considered (mortality reduction of12%), extension to older women would be more advisable, basedon proven benefits and costs, than extension to younger agegroups.     

Choice of surgery for early breast cancer: psychosocial considerations

A prospective study was conducted with early breast cancer patients who had either been offered, or not been offered, a choice of surgery for treatment. The choice involved mastectomy or wide excision plus radiotherapy. Available evidence suggests that the medical outcome between these two options is similar; this study was designed to investigate selected psychosocial outcomes. It was found that whether or not patients were given a choice was of greater relevance to psychosocial outcomes that was the type of operation performed. Providing a choice led to improved reported adjustments with respect to the ability to undertake work, attitudes towards the future, beliefs about coping, and in physical and psychological functioning.     

Chemoprevention of breast cancer: exemestane ready to be tested in study setting

Prevention of breast cancer is difficult, as most risk factors are difficult to control. Therefore, we have not been able to stop breast cancer incidence rates from rising over past decades. Chemoprevention using aromatase inhibitors, such as exemestane, may change this situation. Aromatase inhibitors are very effective and safe in preventing recurrent disease in postmenopausal breast cancer. A recent randomised placebo-controlled trial showed that in healthy women at moderately increased risk of breast cancer, use of exemestane over a 3-year period reduced the risk of breast cancer by 65%. The reduction was from 0.55% to 0.19% per year, with no adverse events or measurable effect on quality of life. If confirmed by larger studies with longer duration of follow-up, preventive use of exemestane may turn out to be the first acceptable alternative for women at increased risk of developing breast cancer. On a population level, implementation of prevention using aromatase inhibitors has the potential to reduce the incidence of breast cancer. However, currently in the Dutch population, 140 women would need to use exemestane for three years in order to prevent one invasive breast tumour. Therefore, large-scale implementation of exemestane is not advised, but the evidence is sufficient to start studies with exemestane.     

After surgery for breast cancer: which mode of surveillance?

Five hundred and ten women attending a specialized breast clinic for follow-up after surgery of early breast cancer (Stage I and II) have been studied. Recurrence was found most often (58%) in symptomatic women who returned to the clinic earlier than planned. Only 3% of asymptomatic patients had recurrent disease. It is concluded that counselling in symptoms of recurrent breast cancer would allow more efficient follow-up.     

Talking about cancer: how much is too much?

Doctors who have not come to terms with their own feelings about serious illness and dying may experience considerable embarrassment and feel ill at ease when discussing these subjects with patients. The problems of communicating with patients and ways in which they can be resolved are reflected upon.     

BresDex: helping women make breast cancer surgery choices

Women diagnosed with early breast cancer face a difficult decision between mastectomy and breast conservation surgery with radiotherapy. BresDex is an interactive decision-making support tool, designed to go together with the assistance and information these women currently receive, to help them in making the right choices. This paper will discuss the concepts behind this decision-making tool, the development of the project and the role of clinical photography within it.     

Chemoprevention of breast cancer by tamoxifen: should we still ask this question?]

Pharmacoprevention of cancer is an attractive concept. For breast cancer, several trials were set up some years ago. The largest one was stopped before its planned date of closure and demonstrated an early appearing reduction in breast cancer occurrence; in contrast, the other two trials did not find such a protective effect. The decision is all the more difficult because of tamoxifen side effects, including carcinogenicity. Currently, no definite conclusion can be drawn.