Issues in Breast Cancer Management

In this issue of Oncology Forum, 3 separate articles have addressed the management of breast cancer. Breast cancer has traditionally been thought of as a disease of the West. In this issue, investigators from 3 regional areas, notably Singapore, Hong Kong, and Taiwan, have reported an increased incidence of this disease in Asia. Moreover, the median age at diagnosis appears to be younger and the hormonal receptor positivity rate lower than that reported in the West.

While breast cancer incidence has increased in the West during the first half of the 20th century, there has been little improvement in age-standardised breast cancer death rates in the USA. However, in 1996, Chu et al. described a sudden reduction in breast cancer mortality during the 1900s,¹ which has been attributed to the efforts of early cancer detection and improvements in treatment (particularly with the use of adjuvant chemotherapy and hormonal therapy during the 1980s). In the UK, although screening mammography was not as commonly practiced, Beral et al. have reported a similar sudden decrease in breast cancer mortality in the 1990s,² and this could have been ascribed to earlier use of adjuvant hormonal therapy with tamoxifen.

With the new advances in various aspects of breast cancer treatment, some of the current issues in the management of breast cancer include the following. With the knowledge of a better understanding of the heterogeneity of breast cancer, there will be more targeted therapy, such as anti-Her2 therapy, for individual patients. The ability to predict which therapies an individual patient is likely to respond to will enable clinicians to optimise therapy at the expense of acceptable toxicity while avoiding the use of toxic drugs for patients who are unlikely to respond. Quality of life is becoming increasingly important in the management of breast cancer due to a combination of factors, including improved prognosis with currently available treatment and the availability of potential new therapies with more tolerable toxicity. As a result, treatment-related morbidity has to be taken into consideration when managing individual patients. One such example is the use of sentinel lymph node sampling, which may avoid unnecessary axillary dissection in a subgroup of patients while reducing post-treatment morbidity. The recognition that advanced breast cancer is now managed as a chronic disease, rather than a terminal disease, is increasingly recognised. The efficacy of selective aromatase inhibitors such as exemestane has been proven in advanced disease, and their role in contributing to adjuvant hormonal therapy in addition to tamoxifen in the setting of breast cancer management are now being investigated.

Doctor Winnie Yeo

Photo Editor

References

1. Chu KC, Tarone RE, Kessler LG, et al. Recent trends in the US breast cancer incidence, survival and mortality rates. J Natl Cancer Inst 1996; 88:1571-1579.

2. Beral V, Hermon C, Reeves G, Peto R. Sudden fall in breast cancer death rates in England and Wales [letter]. Lancet 1995; 345:1642-1643.