Treatment of breast cancer]

EPIDEMIOLOGY IN FRANCE: Breast cancer causes 11,000 deaths annually in France and 25,000 new cases are diagnosed each year. Currently, the overall survival rate is 73% at 5 years and 59% at 10 years. Treatment and outcome depend largely on stage at diagnosis and metastatic extension, but many questions remain open. NON-METASTATIC BREAST CANCER: Breast conserving tumorectomy with nodal dissection and radiation therapy is the rule for small tumors measuring less than 3 cm, although there is still some debate on safety margins and the appropriate attitude in case of invasion. Likewise, there are arguments both for and against primary chemotherapy before tumorectomy. Currently, primary chemotherapy should be given in all cases of inflammatory cancers and preferentially for large tumors. Nodal dissection is essentially a diagnostic procedure and is almost always performed although trials evaluating the value of the sentinel node may have an effect on current attitudes. Despite recent advances in adjuvant therapy, dose and combination of chemotherapy are still open questions. There is however a consensus that chemotherapy should be prescribed for all premenopausal patients with node negative and adverse prognosticators and for all patients under 70 with nodal invasion associated with hormonotherapy after menopause if hormone receptors are positive. METASTATIC BREAST CANCER: At this stage, remission together with quality of life are the primary treatment goals. The best response rates (around 65%) are obtained with polychemotherapy protocols including anthracyclins and complete remission can be obtained in approximately 15% of the patients. There is some hope that chemoresistance may be curtailed with new agents such as vinorelbin or the taxane family. High-dose chemotherapy with hematopoietic rescue is another avenue of research aimed at reducing chemoresistance and improving survival. Overall response to hormone therapy is around 30%. Response rate peaks near 70% in cases positive for estrogen and progesterone receptors, but falls to only 10% if hormone receptors are absent. The role of new hormone therapies using new antiestrogen and antiaromatic compounds remains to be determined. AN ONGOING CHALLENGE: Mortality due to breast cancer has started to decline in developed countries despite increasing incidence. This reduction is undoubtedly related to advances in hormone therapy and adjuvant chemotherapy but also to screening programs and early diagnosis. In the Scandinavian countries, it has been demonstrated that mortality can be reduced to the order of 30 to 40% with mass screening, a challenge which should be met in France.