Breast Cancer Management – Recent Advances
By:  CH Yip, Professor, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur
Date: Aug 2003

Adjuvant Radiotherapy

Adjuvant radiotherapy is essential after breast conserving surgery.  A recent study has shown that postmastectomy radiotherapy to the chest wall has resulted in a 5% benefit in survival.  It is suggested that patients with T3 and T4 tumours,  lymph node involvement especially if more than 4 lymph nodes and  grade 3 tumours may benefit from chest wall irradiation after mastectomy.

Other Adjuvant Therapy

A recent randomized controlled study by T Powles et al using clodronate, a bisphosphonate, as adjuvant therapy in breast cancer for 2 years reduces the incidence of skeletal metastases and there is an improvement in overall survival.  A large study on clodronate as adjuvant therapy is currently underway to determine if this indeed is true.

Herceptin is a monoclonal antibody to HER2-neu which is currently approved for use in metastatic HER-2 overexpressing breast cancers.  A multicentric study is now underway for use of Herceptin as adjuvant therapy in breast cancer, and in 5 years’ time, the results should be available. 

Role of Neoadjuvant (prior to surgery) Chemotherapy versus adjuvant chemotherapy (post surgery)

The role of neoadjuvant chemotherapy (primary chemotherapy) was initially used to downstage Stage 3 cancers that were inoperable to render them operable.  Increasingly primary chemotherapy is being used in large tumours which are clinically Stage 2, to shrink the tumour size to allow Breast Conserving Surgery (BCS) to be carried out.  So far, studies have not shown any survival benefit to this strategy; however this strategy allows the clinician to determine if the cancer is chemo-sensitive, something which cannot be assessed in adjuvant chemotherapy.

Management of Metastatic Breast Cancer (Breast Cancer that has spread to other parts of the body)

The management of metastatic breast cancer is individualized.  Metastatic breast cancer is incurable. However survival can be prolonged with good quality of life by utilizing a combination of chemotherapy, hormonal manipulation, radiotherapy and recent targeted therapy such as Herceptin and Iressa. The new chemotherapeutic agents, hormonal agents, and the immunomodulators are very expensive. Therefore, good judgement and sensitivity should prevail before offering these options.

Conclusion

In conclusion, breast cancer treatment has many therapeutic options, and new data emerges every year especially in the area of new drug development.  There is still very much a tendency to treat depending on a “gut” instinct which may not be correct.  Hence clinical practice guidelines developed on the best evidence available should be used to provide optimum care to a patient with breast cancer.

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The treatment should take into account the patient’s physical, emotional,
psychological and rehabilitation needs. We want to keep the health intact, cure and suppress disease.