Management of locally advanced breast cancer (stage III): a review

Patients classified as having locally advanced breast cancer constitute a heterogeneous population of patients with variable prognoses among subgroups. Analysis of reported series has been complicated by the use of a wide variety of staging classifications and the inclusion by some (and not by others) of inflammatory carcinoma in reporting of end results. In spite of difficulties in this literature review, certain conclusions are possible: The 1983 AJCC-UICC staging system would appear to be a reasonable system for assuring comparability of results in future clinical trials. Although the precise frequency of LABC among series cannot be determined with certainty, this presentation probably constitutes less than 20% of series in the Western world. Recognizing that axillary lymph node status is the single most important prognostic variable in primary breast cancer, it has been reported that LABC with large local tumors are associated with neoplastic involvement of axillary lymph nodes in 65-80% of cases, thus connoting a poor prognosis. Patients with T3N0 lesions may constitute a subgroup of patients with relatively indolent (possibly receptor-positive) disease who might have a reasonably good prognosis compared with other variants of LABC, with approximately 75% to 82% of patients surviving five years with surgery alone. Surgery alone for the overall category of LABC is associated with a 20-31% ten-year survival rate, with local control varying from 50-75% in two reported series. Most radiation therapy (XRT) series deal with patients considered inoperable; hence five-year survival statistics in most series range between 10-20%. Selected radiation therapy series may yield results comparable to surgical series. Where reported, XRT has been associated with median survivals in the range of 25 months. Local control with XRT is likely a function of radiation dose, and the use of external beam or iridium implant boosts to the primary tumor mass for increased local control is worthy of continued study. The combination of XRT and mastectomy appears to be superior to either modality alone in terms of local control and survival, although this conclusion is based on analysis of retrospective studies. Combined modality therapy with systemic therapeutic modalities (hormonal and/or chemotherapy) plus the local modalities of surgery and radiation therapy appear promising. Prospective controlled trials using a uniformly accepted staging classification coupled with gathering of useful biological data (such as cytokinetic perturbation data, receptor information, marker studies, etc) should lead to improved treatment approaches in the future.