Principles of therapy in advanced breast cancer

Advanced breast cancer represents a common clinical problem faced by medical oncologists, internists, surgeons, and radiation oncologists. The medical oncologist or internist is usually the patient's primary physician and is responsible for coordinating the multiple disciplines to optimize the therapeutic management. In the case of locally advanced (stage III) breast cancer, there are far fewer prospective clinical trials on which to base management decisions than are available in the metastatic disease setting. The primary cancer care physician's responsibility is particularly great for coordination of the multidisciplinary approach and integration of medical oncology, radiation oncology, and surgical treatment modalities, however. In the case of metastatic breast cancer, an understanding of the importance of certain clinical factors (that is, hormonal receptors, performance score, disease-free interval, sites and extent of metastasis, and tempo of disease) is crucial to the development of the therapeutic plan in the individual patient. Although entry on a state-of-the-art clinical trial is the appropriate goal, this is not always possible, and an understanding of therapeutic options is essential. Palliation is the key word in the management of metastatic breast cancer, and hormonal therapy is generally the most appropriate course unless the patient is not a hormonal candidate because of sites, extent, or tempo of disease, or because of the known lack of hormonal receptors. Of particular importance is attention to sites of bone metastasis where appropriate radiation therapy and/or surgical intervention can relieve pain or prevent a devastating fracture with resultant loss of mobility and decrease in quality of life.