Intended for healthcare professionals

Clinical Review

Management of breast cancer—Part II

BMJ 2008; 337 doi: (Published 11 July 2008) Cite this as: BMJ 2008;337:a540
  1. Nicholas C Turner, oncologist12,
  2. Alison L Jones, oncologist23
  1. 1Department of Medical Oncology, Royal Free Hospital NHS Foundation Trust, London NW3 2QG
  2. 2Breakthrough Breast Cancer Research Centre, Institute of Cancer Research, London
  3. 3University College London Hospitals NHS Foundation Trust, London
  1. Correspondence to: N C Turner nicholas.turner{at}

    Summary points

    • Adjuvant systemic therapy has substantially reduced breast cancer mortality

    • For oestrogen receptor positive cancers, aromatase inhibitors are more effective than tamoxifen in postmenopausal women

    • Chemotherapy substantially improves the survival of selected patients

    • Commercially available molecular tests may further refine selection of patients for chemotherapy, and validation studies are under way

    Breast cancer comprises a spectrum of related but different cancer subtypes, which have different causal genetic changes, may follow different clinical courses, and require different treatments tailored to the phenotype (fig 1). Here, in this second part of our review on breast cancer, we discuss the recent advances in the systemic therapy of breast cancer, and the current drive to individualise treatment according to patient and tumour factors.

    Fig 1 Diagram showing how breast cancer subtypes influence treatment. Breast tumours at the molecular level cluster into three main subtypes of cancer: luminal-type (with subtypes A and B), HER2, and basal-like. Luminal-type breast cancers express the oestrogen receptor (ER) and related genes and can be targeted with hormonal therapies; the less aggressive (subtype A) cancers may be less sensitive to chemotherapy than the more aggressive (type B) cancers. HER2 breast cancers, characterised by overexpression of the growth factor receptor HER2 with amplification of the HER2 gene, are aggressive with a poor prognosis. HER2 positive cancers can be targeted with the monoclonal antibody trastuzumab and also may be highly chemotherapy sensitive. About half of HER2 positive cancers express the oestrogen receptor. Basal-like cancers do not usually express either of the hormone receptors (oestrogen or progesterone) or overexpress the growth factor receptor HER2, a phenotype named “triple negative.” Basal-like cancers are highly proliferative and have a poor prognosis, although many are highly sensitive to chemotherapy. There is no subtype specific targeted therapy. (The clustering of genome-wide gene expression analysis is adapted from …

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