Should all patients with node-negative breast cancer receive adjuvant therapy? Identifying additional subsets of low-risk patients who are highly curable by surgery alone

Article Abstract:

Breast cancer patients whose cancer has not spread to the lymph nodes of the armpit (axillary nodes) have the best prognosis for this disease. However, the current trend is to treat most of these patients with adjuvant chemotherapy in addition to the surgical removal of the cancer to destroy any microscopically small deposits of cancer cells that might have spread. It would be advantageous, however, to identify women for whom such adjuvant treatment provides no additional benefit. These patients could then be spared both the adverse side effects and the cost and inconvenience of chemotherapy. A study was conducted of 408 breast cancer patients with negative axillary lymph nodes; none of the patients received adjuvant chemotherapy. Nevertheless, four groups of patients could be identified who had seven-year disease-free rates better than 94 percent. These patients constituted one-third of the original breast cancer patients and may be a group who might be spared the risks of adjuvant chemotherapy in clinical practice. The first group consisted of patients with tumors of less than one centimeter which appeared well or moderately differentiated under the microscope. (To the pathologist, a 'differentiated' cancer cell retains many of the characteristics of the normal cells from which it arose.) In the present study, 48 patients fit into this group and all 48 were disease-free at seven years. The second group consisted of 35 patients older than 50 years with poorly differentiated cancers that were still less than one centimeter in size. These patients had a disease-free rate of 97 percent at seven years. The third group consisted of patients older than 50 with cancers between 1.1 and 2.0 centimeters that were well or moderately differentiated. The seven-year disease-free survival was 94 percent for this group. The last group consisted of patients with a specific form of breast cancer called ductal carcinoma in situ with microscopic invasion. The disease-free survival of this group was 100 percent after seven years. The best form of treatment for patients with small breast cancers (less than two centimeters) who do not fall into one of these low-risk groups is not yet certain, but the identification of additional prognostic factors may prove useful. (Consumer Summary produced by Reliance Medical Information, Inc.)

Cancer, Adjuvant chemotherapy

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Risk factors for breast recurrence in premenopausal and postmenopausal patients with ductal cancers treated by conservation therapy

Article Abstract:

The cases of 496 women treated for ductal breast cancer with breast-conserving surgery were reviewed to determine those factors which best predicted the risk of local recurrence in the remaining breast tissue. Twenty-one different factors were studied. Nine factors were significantly associated with increased risk of local tumor recurrence: mononuclear cell reaction, high tumor grade, extensive intraductal component, tumor necrosis, macroscopic multiplicity, absence of estrogen receptors, tumor size, vascular invasion, and age under 40. Not all of these factors are independent, however. Upon multivariate analysis, the most significant factors were found to be mononuclear cell reaction, tumor grade, and intraductal component. It is interesting to consider the correlation of age under 40 years with increased risk of recurrence. Women under 40 are at significantly higher risk of local recurrence; this seems to be due to the fact that extensive intraductal components are more common among women under 50, and both mononuclear cell reaction and high tumor grade are more common in women under 40. Thus, virtually all of the important prognostic factors are related to the histopathological examination of the tumor rather than extrinsic factors, such as radiation dose or family history. The overall risk of local recurrence of ductal breast cancer was 12.3 percent. Patients with moderate or severe mononuclear cell reactions had a 28 percent chance of recurrence. The recurrence rate of premenopausal women without any risk factor was only 2.6 percent at five years. For postmenopausal women, risk was determined primarily by tumor grade and the adequate margins obtained during the surgery. Those with grade 3 tumor and tumor extending to the margin of the removed tissue had a 31 percent chance of local recurrence within five years. Clearly, careful pathological evaluation of the tumor tissue is by far the most important step in evaluating the risk of recurrence in patients with ductal breast cancer. (Consumer Summary produced by Reliance Medical Information, Inc.)

Risk factors, Metastasis, Cancer metastasis

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Ductal carcinoma in situ with microinvasion: a curable entity using surgery alone without need for adjuvant therapy

Article Abstract:

Adjuvant therapy is often recommended for patients with breast cancer whose disease has not spread to the lymph nodes. The rationale for adding this adjuvant chemotherapy is that 15 to 20 percent of such patients having surgical treatment alone will relapse within 10 years. However, these figures represent the total for all the various forms of node-negative breast cancer; adjuvant chemotherapy may be more appropriate for some types of breast cancer than others. Since the advent of mammography, there has been an increase in the detection of ductal carcinoma in situ (DCIS), a type of breast cancer in which cancerous cells are found in their place of origin and have not begun to spread even to the adjacent tissues. In ductal carcinoma in situ with microinvasion (DCISM) there is only limited spread beginning at the edges of the cancer. In a series of 498 breast cancer patients with negative (cancer-free) axillary lymph nodes, 36 were found to have DCISM. In over half the patients, the cancer was not detectable by any means except mammography. All 36 patients received surgical treatment only; 33 had radical mastectomy and 3 had wide excision with removal of the lymph nodes of the armpit. One patient died of a heart attack, and autopsy revealed no signs of breast cancer. The remaining 35 patients are alive without evidence of disease at a median follow-up of 57 months. The disease-free survival rate seems to be 100 percent for this group of patients, which indicates that adjuvant chemotherapy would provide no additional benefit over surgery for patients with DCISM. DCISM was originally considered to be a rare condition, but with the increasing use of mammography greater numbers of patients with DCISM will be diagnosed. In the present study, 8.8 percent of the patients with node-negative breast cancer had DCISM, indicating that the condition is now far from rare. (Consumer Summary produced by Reliance Medical Information, Inc.)

Care and treatment, Surgery, Carcinoma in situ, Mammography

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