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Breast cancer 

Breast cancer

Chapter:
Breast cancer
Author(s):

M. Cariati

, L. Holmberg

, J. Mansi

, P. Parker

, G. Pichert

, S. Pinder

, E. Sawyer

, R. Wilson

, and A. Purushotham

DOI:
10.1093/med/9780199204854.003.130803_update_001

May 30, 2013: This chapter has been re-evaluated and remains up-to-date. No changes have been necessary.

Update:

Screening—use of MRI in young women at very high risk.

Surgery—discussion of indications for complete axillary lymph node dissection following recent trial.

Updated on 30 Nov 2011. The previous version of this content can be found here.
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date: 25 March 2017

Epidemiology and aetiology—over 1 million women worldwide are diagnosed with breast cancer each year, with about 400 000 dying of the disease. Familial breast cancer, most commonly related to the BRCA1 and BRCA2 genes, accounts for only 5% of all cases. Many of the known risk factors are not modifiable because they are inherent or would require unrealistic lifestyle changes, but moderating alcohol consumption, avoiding obesity, and increasing physical activity are all possibly useful interventions.

Prevention—screening for breast cancer is an effective means of achieving earlier diagnosis and provides the opportunity for reducing mortality: X-ray mammography screening alone can be expected to reduce mortality by 30% in women aged 40 to 70 years who participate.

Clinical assessment

Diagnostic assessment of symptomatic breast problems and screen-detected abnormalities is best carried out by multidisciplinary teams following the principles of triple assessment, which involves (1) detailed history and clinical examination of both breasts, axillae and supraclavicular regions; (2) imaging; and (where indicated) (3) cytology/core biopsy. The primary imaging techniques are X-ray mammography and ultrasonography, with MRI when there is diagnostic uncertainty. Ultrasound-guided core needle biopsy is the preferred method for sampling abnormalities. Once the diagnosis has been made, further imaging is used to assess the extent of cancer in the breast and detect the spread of disease to the axilla.

The most significant histological predictors of prognosis are lymph node stage, histological grade, and histological assessment of tumour size, but evaluation of tumour type and the absence or presence of lymphovascular invasion provide additional information, and oestrogen receptor status and HER2 status are predictive markers for selection of therapy.

Management

Surgical treatment—(1) Breast: the main options are modified radical mastectomy, with or without immediate or delayed breast reconstruction, or breast-conserving surgery followed by adjuvant radiotherapy to the breast. (2) Axilla: metastatic involvement of these nodes is the best predictor of risk of recurrence and death, hence accurate assessment of axillary node status is important for staging, prognosis and guiding adjuvant treatment selection; many regard sentinel lymph node biopsy as the best technique.

Radiotherapy—this is an established means of reducing the risk of locoregional recurrence following surgery for invasive breast cancer and also improves survival. It can also be useful for palliation, particularly of bone and brain metastases.

Systemic therapy—(1) endocrine: hormone therapy is only of value in women in whom receptors have been identified histologically by immunohistochemistry; in premenopausal women reduction in oestrogen levels can be achieved by luteinizing hormone releasing hormone (LHRH) agonist or by oophorectomy, or by blocking oestrogen receptors with a SERM (selective oestrogen receptor modulator) such as tamoxifen; in postmenopausal women peripheral aromatization of androgens synthesized by the adrenal glands can be significantly reduced by aromatase inhibitors; (2) chemotherapy: many cytotoxic drugs with different mechanisms of action are available for the treatment of breast cancer (anthracyclines, alkylating agents, antimetabolites, tubulin-binding and platinum-based drugs); (3) biological therapy: Herceptin, a humanized monoclonal antibody against HER2, is active against breast cancers that express this receptor.

Early breast cancer—most women present with local disease confined to the breast, with or without axillary node involvement. Those with hormone-nonresponsive (oestrogen receptor/progesterone receptor, ER/PR –ve) disease should be offered chemotherapy. Those with hormone-responsive (ER/PR +ve) disease should be offered endocrine therapy, with the addition of chemotherapy to some intermediate-risk and all high-risk groups. Herceptin should be given to women following chemotherapy if their tumours are HER2 positive (overexpress the protein or are gene-amplified).

Locally advanced (operable and inoperable), large or inflammatory breast cancers—chemotherapy is the initial treatment of choice, usually anthracycline based followed by a taxane, which can reduce the size of a tumour and render it operable.

Metastatic breast cancer—treatment is aimed at controlling symptoms, improving quality of life, and prolonging survival. Endocrine therapy is usually the treatment of first choice if the tumour is hormone-receptor positive. If the patient has exhausted all endocrine options, or has a hormone-receptor negative tumour, or has rapidly progressive disease, then chemotherapy is the treatment of choice.

Symptomatic treatment—patients with metastatic breast cancer may require pain control with appropriate analgesia; draining of ascites or pleural effusions; radiotherapy for bony pain, brain metastases, or spinal cord compression; and relief of obstructive jaundice by stenting. Symptoms due to bony involvement may be greatly helped by bisphosphonates.

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