Breast Cancer

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December 1st 2007

By the year 2030 most patients with breast cancer will be aged 65 years or more and many will be frail. Frailty implies diminished physiologic reserve; contributors include diminished organ function, comorbidities, impaired physical function, and geriatric syndromes. Time-efficient tools for assessing frailty are being developed and, once validated, can be used to identify frail cancer patients and help direct therapy. Screening mammography in frail patients is questionable, and a clinical breast exam is likely to identify breast cancers that warrant intervention. Hormonal therapy may be a reasonable primary therapy in older frail women with hormone receptor–positive lesions. For estrogen receptor– and progesterone receptor–negative lesions, excision of the primary tumor may be adequate. Adjuvant hormonal therapy may be appropriate in frail elders with high-risk hormone receptor–positive breast cancer; chemotherapy is rarely indicated regardless of tumor status. The majority of frail elders with metastases will have hormone receptor–positive breast cancers, and endocrine therapy should be considered; those with receptor-negative tumors may be treated with single-agent chemotherapy or supportive care measures. Oncologists need to acquire the skills to appropriately identify frail elders so they select appropriate therapies that will minimize toxicity and maintain quality of life.


CME Content


US Food and Drug Administration (FDA) has granted approval of ixabepilone (Ixempra) as monotherapy for the treatment of patients with metastatic or locally advanced breast cancer in patients whose tumors are resistant or refractory to anthracyclines, taxanes, and capecitabine (Xeloda)

Clinical trials have shown significant improvements in disease-free survival when trastuzumab (Herceptin) is added to standard adjuvant chemotherapy in HER2-positive breast cancer patients, but is it appropriate for all such patients, specifically low-risk patients with tumors 1 cm or smaller in size?

Increasing experience with magnetic resonance imaging (MRI) has raised important questions about how it should be used in breast cancer screening, and for presurgical evaluation and posttherapy follow-up of women with this disease. Overall, the availability of MRI as an adjunct to mammography and ultrasound offers clear clinical benefit to women at increased risk of breast cancer development due to BRCA1 and BRCA2 mutations, and to women presenting with axillary adenopathy and an occult primary breast tumor. In contrast, its benefit for routine selection of breast conservation or further assessment of lobular carcinoma in women of average risk has not been demonstrated.This article reviews the use of MRI in these settings, with an emphasis on the clinical outcomes that have been observed to date.

Increasing experience with magnetic resonance imaging (MRI) has raised important questions about how it should be used in breast cancer screening, and for presurgical evaluation and posttherapy follow-up of women with this disease. Overall, the availability of MRI as an adjunct to mammography and ultrasound offers clear clinical benefit to women at increased risk of breast cancer development due to BRCA1 and BRCA2 mutations, and to women presenting with axillary adenopathy and an occult primary breast tumor. In contrast, its benefit for routine selection of breast conservation or further assessment of lobular carcinoma in women of average risk has not been demonstrated.This article reviews the use of MRI in these settings, with an emphasis on the clinical outcomes that have been observed to date.

Gemcitabine (Gemzar), which is approved in combination with paclitaxel (Taxol) in the first-line, postsurgical treatment of metastatic breast cancer, was the subject of a study presented at the 43rd annual meeting of the American Society of Clinical Oncology (ASCO), with encouraging results in the presurgical treatment of breast cancer.

In patients with locally advanced breast cancer, adding trastuzumab (Herceptin) to chemotherapy prior to surgery significantly increases pathologic complete response rates, compared with chemotherapy alone.

Martin D. Abeloff, MD, the chief oncologist and director of the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, died September 14, 2007, of leukemia. Dr. Abeloff, 65, an international authority on the treatment of breast cancer, was co-Editor-in-Chief of ONCOLOGY and founding Editor-in-Chief of Oncology News International.

In a phase I study, 7 of 18 patients with measurable advanced breast cancer receiving sunitinib (Sutent) and paclitaxel as first-line therapy had an objective response (38.9%), including two complete responses, researchers reported at the ASCO Breast Cancer Symposium

There may be a small subset of women with DCIS who may not benefit from radiation therapy, but researchers maintain that this particular group has not yet been defined, and until they are clearly defined, radiation therapy remains the standard of care for those patients with DCIS who opt for breast-conserving surgery.

Conventional wisdom holds that DCIS consists of malignant cells that have not invaded other tissue, but László Tabár, MD, has identified subtypes that he thinks are actually invasive and merely mimic DCIS. Fragmented casting (as seen on the page 1 image) and "snakeskin-like" calcifications, appearing either alone or with a mass on the mammogram, are particularly menacing, he maintains.

Disease-free and overall survival have improved significantly for women diagnosed with early-stage breast cancer. At the same time, systemic therapy has only slightly enhanced long-term outcomes in advanced breast cancer, a disease that remains largely incurable. Several single-agent and combination chemotherapy approaches are available to women with hormone-insensitive advanced disease that may improve overall survival and progression-free survival, minimize symptoms and complications related to the disease, and improve overall quality of life. In addition, new cytotoxic and targeted agents have been recently introduced into practice and have improved both survival outcomes and quality of life. In this review, we will provide an update on commonly used chemotherapy-based regimens for the treatment of metastatic breast cancer, with a focus on tailoring therapy to different subtypes of the disease.

One of the primary challenges in the treatment of patients with early-stage breast cancer is determining which patients will benefit from adjuvant chemotherapy. Traditionally, treatment decisions have been made based on a combination of tumor characteristics and patient and physician perspectives regarding risks and benefits. Recent technologic advances, including the development of gene-expression arrays, have led to the identification of molecular signatures that provide prognostic information in addition to the basic clinicopathologic features of individual tumors. While these new methods allow for more refined determination of prognosis for an individual patient, few data are available to support use of these new technologies in the clinic for treatment decision-making. At present, data from a single retrospective study are available to support the use of one assay, the 21-gene recurrence score, for decision-making regarding adjuvant chemotherapy. Large, multinational clinical trials are currently ongoing to evaluate the use of two of the multiparameter assays, although it will be many years before oncologists can apply the results of these trials in the clinic.