Intended for healthcare professionals

Practice ABC of breast diseases

Medical treatment of early breast cancer. I: adjuvant treatment

BMJ 2006; 332 doi: (Published 05 January 2006) Cite this as: BMJ 2006;332:34
  1. Ian Smith, professor of cancer medicine,
  2. Susan Chua, medical oncologist
  1. Royal Marsden Hospital, London
  2. Melbourne, Australia.

    The past decade has seen an impressive fall of around 15% in deaths from breast cancer in the United Kingdom, and this has occurred in the face of a rising incidence. This fall coincides with the widespread national uptake of adjuvant systemic therapy and with increasing evidence of its benefit for survival.

    More than half the women with operable breast cancer who receive only locoregional treatment die from metastatic disease. This indicates that micrometastases are present at initial clinical presentation. The major risk factors for the development of metastatic disease are the involvement of axillary nodes, a poor histological grade, large tumour size, and histological evidence of lymphovascular invasion around the tumour site. The absence of oestrogen and progestogen receptors, and the overexpression of the human epidermal growth factor receptor 2 (HER2), also carry an adverse prognosis. The way to improve survival is to give these women systemic medical treatment, including endocrine therapy, chemotherapy, or targeted therapy with trastuzumab along with surgery.

    Trends since 1950 in age standardised death rates for breast cancer and other types of cancer among women in the United Kingdom. The fall in mortality since 1990 has been caused mainly by the introduction of adjuvant therapy as a consequence of results from clinical trials. Data from WHO mortality and United Nations population estimates

    Systemic treatment may be given after (adjuvant) or before (neoadjuvant, primary, or preoperative) locoregional treatment. Adjuvant treatment has been shown to be effective in randomised clinical trials, whereas the evaluation of neoadjuvant systemic therapy is ongoing. The effectiveness of adjuvant treatment cannot be assessed in individual patients because there is no overt disease to monitor, and trials that compare different adjuvant therapies take years to produce results; this is an important problem when trying to assess the role of active new drugs in …

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