Breast cancer

The management of patients with breast cancer has been changing over the last few years and this article highlights some areas of particular interest. The changes have been brought about against a background of an increasing disease incidence coupled with increasing political aspirations from patients and their relatives. This paper focuses on organisational aspects of breast cancer care, screening, induction and high-dose chemotherapy, clinical trials, genetics, training of surgical and nonsurgical oncologists and future prospects.     

Breast cancer and pregnancy

Breast cancer treatment during pregnancy involves a host of psychosocial, ethical, religious, and even legal considerations, as well as medical multidisciplinary decisions, since the effect of treatment on the fetus must be considered. For example, breast or chest wall radiotherapy should be avoided. The absorbed fetal dosage is at least 5 cGy early in pregnancy and increases to several hundred cGy late in pregnancy to the fetal part immediately below the diaphragm. In the second and third trimesters, chemotherapy is associated with intrauterine growth retardation and prematurity in about half of the babies; the risk of birth defects is a concern in the first several weeks. Typical anesthetic agents readily reach the fetus but are not known to be teratogenic. Although abortion will allow full and comprehensive treatment to the mother, it is not known whether the procedure itself is therapeutic. Early in pregnancy, abortion deserves strong consideration, since the effects of treatment on the fetus will not be a consideration. The poor prognosis of pregnancy-associated breast cancer in the past is probably attributable to a combination of initial delay of diagnosis and possibly to unfavorable biologic characteristics of the hormonal milieu of pregnancy. When pregnant patients are matched stage for stage with controls, survivals seem equivalent, although pregnant patients present with more advanced disease.     

A summary of cancer screening guidelines

Guidelines and programs for the early detection of cancer or cancer screening are based on the premise that outcomes are improved if the cancer is diagnosed and treated at the early stages of disease. However, there are also disadvantages to the early detection of cancer that must be considered when evaluating and establishing guidelines and programs. The Cancer Bureau of the Laboratory Centre for Disease Control at Health Canada has compiled a summary of existing guidelines for the early detection of various cancers. Recommendations have been provided by governmental organizations, non-governmental organizations, health agencies and professional associations. Many organizations base their guidelines on current evidence and periodically update them as new evidence becomes available. Therefore, it is our intention to revise this compilation in the future to reflect any updates. Guidelines for the early detection of cancer are listed in the tables that follow for 12 different cancer sites: breast, cervical, prostate, colorectal, ovarian, skin, testicular, gastric, lung, pancreatic, bladder and oral cancers.     

Breast cancer in older women

The American Geriatric Society currently recommends screening mammography for women up to 85 years of age whose life expectancy is three years or longer. The value of clinical breast examinations in older women needs further study. Total mastectomy and partial mastectomy with postoperative radiation therapy yield similar results in localized breast cancer. Postoperative irradiation may be avoided in women with small tumors (2.5 cm or less in diameter) who have undergone quadrantectomy. Lymph node dissection is important for tumor staging but significantly increases the risks and morbidity of surgery. Lymph node mapping may obviate the need for lymphadenectomy in many older women. Adjuvant hormonal therapy for at least two years appears to be beneficial in all women with hormone-receptor-rich tumors. Adjuvant chemotherapy is indicated in women with lymph node involvement or high-risk tumors with no lymph node involvement. Unless life-threatening metastases are present, hormonal therapy is the first approach to metastatic cancer. Chemotherapy is indicated if endocrine therapy is unsuccessful or life-threatening metastases are present. Most chemotherapy regimens appear to be well tolerated, even by women over 70 years of age. Special treatment should be employed for metastases to tumor sanctuaries (i.e., brain, eyes), the long bones, the spine and the chest wall.     

Breast cancer screening programmes in 22 countries: current policies, administration and guidelines. International Breast Cancer Screening Network (IBSN) and the European Network of Pilot Projects for Breast Cancer Screening

BACKGROUND: Currently there are at least 22 countries worldwide where national, regional or pilot population-based breast cancer screening programmes have been established. A collaborative effort has been undertaken by the International Breast Cancer Screening Network (IBSN), an international voluntary collaborative effort administered from the National Cancer Institute in the US for the purposes of producing international data on the policies, funding and administration, and results of population-based breast cancer screening. METHODS: Two surveys conducted by the IBSN in 1990 and 1995 describe the status of population-based breast cancer screening in countries which had or planned to establish breast cancer screening programmes in their countries. The 1990 survey was sent to ten countries in the IBSN and was completed by nine countries. The 1995 survey was sent to and completed by the 13 countries in the organization at that time and an additional nine countries in the European Network. RESULTS: The programmes vary in how they have been organized and have changed from 1990 to 1995. The most notable change is the increase in the number of countries that have established or plan to establish organized breast cancer screening programmes. A second major change is in guidelines for the lower age limit for mammography screening and the use of the clinical breast examination and breast self-examination as additional detection methods. CONCLUSION: As high quality population-based breast cancer screening programmes are implemented in more countries, they will offer an unprecedented opportunity to assess the level of coverage of the population for initial and repeat screening, evaluation of performance, and, in the longer term, outcome of screening in terms of reduction in the incidence of late-stage disease and in mortality.     

Breast cancer and body build

The purpose of this study was to evaluate the prognostic value of neonatal E.E.G. tracings in children born at term. The clinical course of 45 children was followed and related to E.E.G. abnormalities reported during the first 5 days of life. Essentially the findings confirmed those previously reported by others. However some differences were noted: paroxysmal tracings were not associated with a poor clinical state, and moderately abnormal tracings (the prognostic significance of which has never been defined) led on sometimes to a severe encephalopathy. We wish to stress certain aspects of our findings: -recordings in the first 24 hours of life may be misleading. -recordings, to be of value, must be taken before any treatment which could induce paroxystic E.E.G. patterns. -E.E.Gs should be repeated during the post-natal period when the findings are non-specific. -the prognostic significance of tracings reported as "generalised or localised overactivity" should be evaluated.     

Breast cancer in older women

Successful laser treatment of haemangiomas requires selective photocoagulation of subsurface targeted blood vessels without thermal damage to the overlying epidermis. We present an in vivo experimental procedure, using a chicken comb animal model, and an infrared feedback system to deliver repetitive cryogen spurts (of the order of milliseconds) during continuous Nd:YAG laser irradiation. Gross and histologic observations show deep-tissue photocoagulation is achieved, while superficial structures are protected from thermal injury due to cryogen spray cooling. Experimental observation of epidermis protection in chicken comb animal models suggests selective photocoagulation of subsurface targeted blood vessels for successful treatment of haemangiomas can be achieved by repetitive applications of a cryogen spurt during continuous Nd:YAG laser irradiation.     

Breast cancer genes and the surgeon

There are currently over 150 patients receiving daily hemodialysis in over 12 centers worldwide. The experiences of over 200 daily hemodialysis patients spanning 30 years have been reviewed. The reports uniformly describe subjective and objective improvements. There are decreased symptoms during and after dialysis, improved functional status, and better quality-of-life ratings. There are improved nutritional indices, improved blood pressure with fewer blood pressure medications, and improved hematocrit with reduced transfusion or eythropoietin requirements. There also appear to be economic advantages, related to the significant reductions in the need for recombinant human erythropoietin and blood pressure medications. Early data suggest that there may be a significant decrease in days of hospitalization for very ill patients as well. This is important clinically and financially when the global costs of caring for dialysis patients are considered. Substantial issues remain before daily hemodialysis will be widely accepted. These include logistical problems (additional time for transportation, set up and disinfection), economic problems (increased supply costs or labor associated with more frequent treatments), and medical problems (deficiency syndromes and blood access). Technological improvements are close to overcoming many of the recognized problems, although additional payor education, research into deficiency syndromes, and an even greater focus on creating natural arterio-venous fistulae all need to occur before daily hemodialysis is more widely accepted. We are convinced, however, that daily dialysis will be increasingly used in the next century because it is more physiologic, makes many patients feel much better, produces better outcomes, and decreases overall cost for end-stage renal disease patients compared with current dialysis regimes.     

Breast cancer arising in surgical scars

Twelve women who developed breast cancer at the site of old surgical scars in the breast are presented. Six had had former breast biopsies, 3 drainage of breast abscesses, and 3 developed breast cancer in old thoracotomy scars transversing the breast. The combination of trauma as an oncogen and scar tissue as a functional and immunological locus minoris resistentia seems to play a major role in the development of breast cancer in this group of patients. The associaton of breast cancer, scar, and trauma would not be coincidental. Increased attention drawn to this entity may lead to a rise in the number of cases diagnosed among patients with breast scars after biopsies, abscesses, trauma, or foreign body implantation.     

Head and neck cancer: guidelines for chemotherapy

Head and neck cancer is estimated to be one of the most prevalent cancers in the world. This tumour type accounts for 5% of all new cancer cases in the US and Europe each year. Patients with locally recurrent or metastatic squamous cell carcinoma of the head and neck have a poor prognosis, with a median duration of survival between 4 and 6 months. During the past few years, screening for potentially active new compounds, new associations and new modalities of chemotherapy administration have had some degree of success. Clinical investigations have also focused on the addition of chemotherapy to locoregional treatment for patients with locally advanced disease. Induction chemotherapy or concomitant chemo- and radiation therapy can result in high response rates, and reduced incidence of distant metastases. However, there is no clear demonstration of any benefit from the addition of chemotherapy to locoregional therapy on overall survival in patients with resectable disease. In patients with resectable laryngeal or hypopharyngeal cancer, chemotherapy combined with radiotherapy can be considered as a standard treatment option for larynx preservation, keeping total laryngectomy reserved for salvage therapy. In patients with unresectable head and neck cancer, simultaneous chemoradiotherapy has been shown to improve locoregional control and survival, at the cost of greater toxicity. Outside clinical trials, this approach can also be considered as a standard therapy for unresectable disease.