Management of breast cancer

Hormonal therapy, surgical and medical ablation procedures, and the use of palliative cytotoxic and adjuvant chemotherapy in the management of breast cancer are reviewed. Breast cancer staging systems are described that use various clinical and histological criteria in choosing the most appropriate therapy and in predicting therapeutic response. Estrogen and progesterone receptor titers now allow for a more reliable prediction of whether palliative hormonal therapy or cytotoxic drug therapy is preferable. Endocrine methods include surgical ablative procedures, additive hormonal therapy, and antiestrogenic therapy with tamoxifen or aminoglutethimide. Aminoglutethimide appears to be at least as efficacious as surgical adrenalectomy and hypophysectomy in treating hormonally sensitive tumors in women with advanced breast cancer, and it is associated with a lower incidence of complications than surgical ablation procedures. Tamoxifen appears to be at least as effective as other forms of endocrine treatment, and it is now preferred to diethylstilbestrol in the treatment of postmenopausal women. Compared with androgens, progestogens, and glucocorticoids, estrogens have the highest rate of objective response in the treatment of advanced breast cancer; however, the use of estrogens has diminished since tamoxifen is associated with similar efficacy and a lower incidence of side effects. Palliative cytotoxic chemotherapy is used for those women who have low titers of hormone receptors, rapidly progressing disease, widespread disease to visceral organs, or tumors that are refractory to hormonal therapy. Combinations of cytotoxic agents yield response rates and durations of response that are superior to single-agent therapy. Attempts are being made to enhance the "cure" rate, postoperative disease-free intervals, and survival times for women who have undergone surgical resection of the breast tumor. The benefits of adjuvant cytotoxic chemotherapy are particularly evident for pre- and postmenopausal women with three or less involved lymph nodes. The potential merits of adjuvant hormonal therapy and combination therapy with hormones and cytotoxic agents are being studied.