Education And Debate

ABC of breast diseases: Role of Systemic Treatment for Primary Operable Breast Cancer

BMJ 1994; 309 doi: (Published 19 November 1994) Cite this as: BMJ 1994;309:1363
  1. M A Richards,
  2. I E Smith,
  3. J M Dixon

    Over half of women with operable breast cancer who receive locoregional treatment alone (surgery with or without radiotherapy) will die from metastatic disease, indicating that for most women the cancer has already spread by the time of presentation. The major risk factors for development of metastases are axillary lymph nodes being involved, an adverse histological grade (indicating an undifferentiated cancer), and large tumour size. Combinations of these factors can be used to define groups with widely different risks of relapse: from less than 10% to more than 90% remaining free of disease after five years. The only way to improve the chance of survival for many of these women is to give them effective systemic treatment.

    Survival without relapse of patients with operable breast cancer (data from Guy's Hospital, London).

    Systemic treatment may be given either as adjuvant treatment after locoregional treatment or as primary systemic treatment before locoregional treatment. The effectiveness of adjuvant treatment has been clearly shown in clinical trials, while primary systemic treatment is still being evaluated. A problem with adjuvant treatment is that its effectiveness in individual patients cannot be assessed as there is no overt disease to monitor. In contrast the effectiveness of primary medical treatment can be assessed by monitoring the size of the primary tumour. Primary medical treatment in operable breast cancer can result in shrinkage of a tumour; thus, a large tumour initially treatable only by mastectomy can be made suitable for breast conserving treatment.

    Outline of options for systematic treatment of large, operable breast cancer.

    One potential problem with primary systemic treatment is that, if the diagnosis of cancer is made by fine needle aspiration cytology alone, in situ disease could be treated by chemotherapy (cytology cannot differentiate invasive and in situ disease). For this reason most units perform core or …

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