We searched the Cochrane Library (data range) and MEDLINE (data range), using the search term “breast cancer”. We mainly selected publications in the past 5 years, but did not exclude older reports that were commonly referenced and highly regarded. We also searched the reference lists of articles identified by this search strategy and selected those we judged as relevant. Several review articles or book chapters were included because they provided comprehensive overviews that were beyond
SeminarBreast cancer
Section snippets
Causes of disease
Nowadays, the identification of effective strategies and interventions to prevent breast cancer is still challenging. Although women who have first-degree relatives with a history of the disease are at increased risk, a major pooled analysis has revealed that they are unlikely to ever develop breast cancer, and most who do will be older than 50 years when diagnosed. In countries where breast cancer is common, the lifetime excess incidence of breast cancer is 5·5% for women with one affected
Possibilities of chemoprevention
In the past few years, hormonal intervention using tamoxifen has been shown to reduce the risk of oestrogen-receptor-positive breast cancer.32 Although such findings are good with respect to proof of principle, the degree of side-effects from tamoxifen, some clinically serious and others affecting quality of life, seem to rule out the drug for general use at present.
Our knowledge of breast carcinogenesis remains incomplete. We still have no comprehensive understanding of the mechanisms of
Progression from healthy tissue to invasive carcinoma
Because of the longlasting debate on the preneoplastic potential of benign, proliferative lesions of the breast (ie, florid ductal hyperplasia in fibrocystic disease), a definitive progression model (similar to that for colon adenocarcinoma) has not been determined. Current knowledge on mammary dysplasia is far from reliable. Indeed, cytological or architectural dysplastic changes can be located in various non-malignant breast diseases, such as florid and columnar duct hyperplasia, adenosis,
Diagnosis and staging
The revolution in diagnostic imaging during the past 20 years has greatly changed detection and diagnostic strategies in breast cancer. Moreover, organised screening, education programmes, and improved consciousness of the female population have substantially changed the type of patients seen nowadays compared with those a few decades ago.
Surgery
Once imaging techniques indicate a tumour in the breast, cytological or histological confirmation is vital before further treatment is given. Cytology is effective in solid lesions, especially if sonographically guided.60 But knowledge of the histology of the lesion is the most useful for surgeons, which can be obtained by a core biopsy. A tru-cut biopsy is the simplest method for palpable lesions that are easily reached, whereas a vacuum-assisted needle biopsy can obtain enough material for a
Radiotherapy in breast conservation
In most developed countries, the current standard of care for patients with early-stage breast cancer consists of breast-conserving surgery, followed by 5–6 weeks' postoperative radiotherapy. Women treated with this protocol have similar prognosis to those treated with mastectomy. Although avoidance of breast irradiation was shown to substantially raise local recurrence, the necessity of radiotherapy in breast conservation strategy is still debated.68 Some subgroups of patients could
Systemic treatments
Patients who remain free of disease after adjuvant therapy compared with those needing chronic care to constantly control disease progression is the main difference between adjuvant and the metastatic treatment approaches, respectively. Adjuvant systemic therapy is given to attempt eradication of micrometastatic disease, which could potentially be present in all patients with invasive breast cancer. Its aim is to reduce relapse and increase survival. Postoperative adjuvant therapies cannot be
Systemic treatments for women with overt metastases
Overt metastases usually indicate chronic, incurable disease. Treatments are defined according to efficacy to provide palliation and account for a heterogeneous duration of survival, which could vary from a few weeks to several decades (with an average of a few years). Treatment should increase the total duration of time with no or few disease-related symptoms and with the lowest burdens with respect to side-effects of treatment.145 Although some trials with selected patients have shown, on
Molecular targets and new drugs
The rapid growth in the number of biomolecular markers and development of targeted therapeutic drugs for breast-cancer treatment began more than three decades ago after the discovery of steroid-hormone receptors.150 Increased knowledge of several tyrosine-kinase family receptors has led to the first targeted treatment beyond endocrine therapies, the humanised murine antibody trastuzumab. Assessment of potential molecular targets has therefore become an important part of primary diagnosis to
Conclusions
Although care for patients with breast cancer is genuinely mutlidisciplinary, there is an important general trend to increase targeted interventions within all specialties to obtain efficacious treatment with acute and late toxic effects in organs and tissues kept to a minimum. It is within this context that progress should be viewed; development of tailored adjuvant systemic therapies and better targeted treatments for women with advanced disease. Both approaches will need an improved
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