Breast Cancer, 1997
The good news about breast cancer in 1997 is that mortality rates in the United States
are finally beginning to fall. Rates for breast conservation are tending upward, and there
is growing consensus on the appropriate use of adjuvant systemic treatment after local
control of the disease. On the other hand, this entity remains the disease most feared by
women, with an estimated incidence of more than 180,000 and a mortality rate of over
44,000 for 1997.
Commensurate with the importance of the disease, Cancer Control continues to
devote a substantial proportion of its editorial content to breast cancer. For example,
the status of the tamoxifen breast cancer prevention study was reviewed by Bernard Fisher,
MD, et al, in Vol. 4, No. 1. In Vol. 2, No. 3, the rapidly emerging fields of breast
cancer genetics and genetic counseling were reviewed by June Peters, MS, and cancer
screening issues were highlighted by Robert Clark, MD. The issue of screening mammography
in the 40- to 49-year-old age group remains clouded. Our own sense is that it is of value
to individuals, but it is expensive public health policy.
This issue of Cancer Control addresses other aspects of management. Drs William
Small and Monica Morrow draw on their vast experience to present many factors to consider
and key principles to follow in order to provide optimal local control of cancer in the
affected breast. They enumerate several medical conditions that are relative or absolute
contraindications to breast conservation, but they note that the majority of women who
present with clinically localized breast cancer are appropriate candidates for the breast
conservation approach. They also review the factors that are associated with local
persistance or recurrence of disease. Demonstration of histologically or cytologically
verified clear surgical excision margins is a particularly important component of
successful breast conservation therapy for either in situ or invasive cancer. This issue
is too often ignored or only partially considered by surgeons and pathologists.
Techniques are rapidly being developed and evaluated for sampling axillary lymph nodes
rather than performing a complete axillary dissection with its attendant costs and
morbidities. Dr Douglas Reintgen and coworkers report studies from our institution
indicating that sampling of only one to two "sentinel" nodes will provide a
remarkably accurate representation of the true status of lymph node metastasis in the
axilla, especially when newer pathology techniques, such as evaluation by
immunohistochemistry or the use of polymerase chain reaction (PCR) for cytokeratin or
other markers of metastasis in lymph nodes, are added to classical histology. The dilemma
concerning recommendations for patients who have histologically negative nodes but
cytokeratin and/or PCR-positive nodes is already with us. Another current problem relates
to study eligibility. Many clinical research studies that are currently active for
"node-negative" patients require that a minimum number of nodes (often at least
10) be removed and evaluated to confirm the node negativity before a patient is eligible
for randomization. Thus, patients who are determined to be "node-negative" by a
sentinel node procedure are ineligible. We presume that rapid validation of the new
technique plus continued training on this approach for surgeons and nuclear medicine
specialists will lead to appropriate protocol modifications. It is interesting to
speculate whether an alternative method of sampling axillary nodes with laparoscopic
techniques will become a clinically useful approach.
Although several aspects of radiation therapy in breast conservation treatment were
discussed in the first paper in this issue by Drs Small and Morrow, other factors that
also govern long-term results after radiation are presented by Dr Harvey Greenberg. Breast
and soft-tissue reactions, skin care, treatment of regional node areas, treatment with
implants, timing of radiation with chemotherapy, and long term-prognosis and follow-up are
highlighted and discussed in this clinically oriented review.
Medical oncology input is provided by Drs Frank Cummings and Nabil Saba. They address
some aspects of in situ disease -- an increasingly important entity because of its high
incidence and lack of clear guidelines on optimum management, despite the excellent
prognosis for survival. Clearly, the longer one follows patients with ductal carcinoma in
situ who have received breast-conserving therapy, the greater the local recurrence rate.
Controversies associated with systemic therapy for breast cancer -- in both the adjuvant
and the advanced disease setting -- include hormone vs cytotoxic approaches, roles for
high-dose chemotherapy, and the duration of tamoxifen treatment. The perspective of the
authors on these controversies is reasoned and fair. Their reluctance to place undue
weight on preliminary or unsubstantiated new information is salutary.
This issue of Cancer Control cannot address all of the myriad current issues
surrounding breast cancer research and care in 1997. We draw your attention, therefore, to
the supplement to this issue. A group of nationally recognized experts in breast cancer
convened in Tampa, Fla, in late February 1997. They defined the key issues surrounding
systemic therapy for breast cancer, reviewed the latest information on each issue, and
then described the implications for both clinical research and clinical care. The taxanes,
as well as other new and promising drugs, were reviewed. The edited deliberations of this
outstanding group constitute the content of the supplement. Several developments are
pertinent to enhanced care. We hope that you both enjoy and benefit from reading this
supplement. We remind you that the journal and its supplements are also available on the
Internet at http://www.moffitt.usf.edu/pubs/ccj/.
John Horton, MB, ChB, FACP
Professor of Medicine and Associate Dean, Education
University of South Florida College of Medicine
Division of Medical Oncology and Hematology
H. Lee Moffitt Cancer Center & Research Institute
Tampa, Fla
Charles E. Cox, MD
Professor of Surgery
University of South Florida College of Medicine
Program Leader, Comprehensive Breast Cancer Program
H. Lee Moffitt Cancer Center & Research Institute
Tampa, Fla
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