An update on the medical management of breast cancerBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3608 (Published 09 June 2014) Cite this as: BMJ 2014;348:g3608
All rapid responses
We are writing in response and wish to congratulate the authors for a very concise and accurate account of the medical management of breast cancer (BMJ 2014;348:g3608).
As regards early breast cancer (local therapy section of the article), there is wide variation in Mastectomy vs. Breast conservation surgery (BCS) rate in the developed versus developing world. There is also wide variation in Mastectomy vs. Breast conservation surgery (BCS) rate in the different units in the same country in the western world.
The rate of Breast Conservation surgery for Breast cancer treatment has steadily expanded, ever since the pioneering work by Veronesi at al, who published the long-term results of the first randomised trial in 1986 on over 700 patients (ref 1). Subsequently two systematic reviews, one involving six randomised trials and 2nd review was a meta analysis of nine randomised trials confirming the oncological safety and survival equivalence of breast conservation to Mastectomy (ref 2, 3). Many studies have shown that Breast conservation surgery (BCS) results in lower level of psychological morbidity and improved body image (ref 4, 5).
The application of Neoadjuvant Chemotherapy and endocrine therapy, as well as oncoplastic techniques has further expanded the role of Breast conservation (BCS) safely in patients previously deemed to be not fit for BCS.
The reason for this variation in practice is multiple including the following.
1. Patient preferences
2.Surgeon related variables and preferences
3.Tumour and patient related variables making Mastectomy the safest option.
4.Demographical factors such as the availability and distance to the nearest radiotherapy facility and the wide spread availability of Specialist Breast Units and surveillance imaging such as Mammography/ Breast Magnetic Resonance Imaging etc.
We compared one typical District General Hospital in the UK figures of Mastectomy rate (29%) and BCT rate (71%), with figures of secondary radiotherapy facility in the developing world. In the same period Institute of Radiotherapy and Nuclear Medicine (IRNUM) Peshawar, in the Northwest of Pakistan, treated 263 patients out of a total 418 patients with primary surgery followed by adjuvant therapy. The remaining patients presented at an advanced stage. All the 263 patients who had surgery as initial treatment has had mastectomy (100% ).
Some or all of the above mentioned reasons are responsible for the evident differences in mastectomy rate. A one hundred percent mastectomy rate at a secondary referral centre with reasonable facilities for imaging and adjuvant therapy is unacceptable. Although a sizeable proportion of patients present at an advanced stage in developing countries, surgeons’ ignorance of survival equivalence of BCS probably is also to blame.
Breast Cancer organizations such as British Association of surgical oncology, European society of surgical oncology, world oncology forum, and medical Royal colleges etc, are doing a great service to humanity by organising Breast cancer conferences around the world and sponsoring fellowships from the developing countries.
British Medical Journal (BMJ) is uniquely placed to help bring change in the breast cancer care in the developing world, particularly those countries and communities where English is the medium of education by frequent articles on this very important topic. This will further improve the clinical outcome and enhance the psychological and physical wellbeing of these, not so fortunate patients around the world.
Ahmad Saeed * Murtaza Salem* Ilyas Abbas #,
* Kettering General Hospital NHS Foundation Trust
# Institute of Radiotherapy and Nuclear Medicine (IRNUM) Peshawar, Pakistan.
Main author, Ahmad Saeed * E-mail: firstname.lastname@example.org
1. 8Veronesi U, Banfi A, Del Veccheio M et al.
Comparison of Halsted mastectomy with quadrant-ectomy, axillary dissection and radiotherapy in early breast cancer: Long term results. Eur J Cancer Clin oncol 1986; 22:1085-9.
2. Early Breast Cancer Trialist’s Collaborative Group. Effects of radiotherapy and surgery in early breast cancer: an overview of the randomised trials.
N Engl J Med 1995; 333:1444-55.
3. Morris AD, Morris RD, Wilson JF et al.
Breast conserving therapy versus mastectomy in early stage breast cancer: a meta-analysis of 10 year survival. Cancer J Sci Am 1997; 3:6-12.
4. Al-Ghazal SK, Fallowfield L, Blamey RW.
Comparison of psychological aspects and patient satisfaction following breast conserving surgery, simple mastectomy and breast reconstruction.
Eur J Cancer 2000; 36:1938-43.
5. Shain WS, d’Angelo TM, Dunn ME et al.
Mastectomy versus conservative surgery and radiation therapy: psychological consequences.
Cancer 1994; 73:1221-8.
Competing interests: No competing interests
Could the authors please give advice as to the value of aspirin in preventing relapse assuming no contra indication and post op
Competing interests: No competing interests
I enjoyed the overview of breast cancer management and the authors have done well to summarize a large body of work. It is stated that aromatase inhibitors (AIs) are "superior" to tamoxifen and that data showing an improved survival for AIs are awaited. AIs are associated with an improvement in disease-free survival, and patients certainly appreciate control of their cancer. What most patients want from their therapy, however, is improved quality of life and longer life. Conventionally-analysed data from adjuvant AI trials, which include tens of thousands of patients (with some of the trial recruitment starting last century), have uniformly failed to show any survival advantage of AIs in the adjuvant setting. Most clinicians would not rate AIs as offering an improved quality of life over tamoxifen. We are, perhaps, deluding ourselves that the survival advantage for AIs is just around the corner, and given the extra 3% absolute survival advantage for tamoxifen shown in the aTTom and ATLAS studies of 10 years versus 5 years of treatment, surely tamoxifen should be the drug of choice for all patients in the adjuvant setting?
 Davies C, Pan H, Godwin J, Gray R, Arriagada R, Raina V, et al. Adjuvant Tamoxifen: Longer Against Shorter (ATLAS) Collaborative Group. Long-term effects of continuing adjuvant tamoxifen to 10 years versus stopping at 5 years after diagnosis of oestrogen receptor-positive breast cancer: ATLAS, a randomised trial.Lancet 2013 Mar 9;381(9869):805-16.
Competing interests: Have participated in commercial and non-commercial trials with AstraZeneca; Novartis; and Roche; some trials have involved payment to my department; no direct payments received by me from pharmaceutical companies.