Sex hormone-binding globulin and the natural history of breast cancer

Low concentrations of SHBG in the blood appear to be related to rapid tumour growth rates whereas normal values are associated with slower rates. The inferences drawn from these and other experimental results are as follows: 1. It is no longer necessary to postulate that an abnormal endocrine environment is related to the risk of breast cancer. 2. Variation within the normal range of endocrine function may be sufficient to account for marked differences in the growth rates of transformed cells. 3. It is suggested that women whose tumours arise in an environment characterised by SHBG concentrations at the lower end of the normal range (and, hence, non-SHBG-bound oestradiol levels at the top end of the range) will tend to have an earlier age at diagnosis, a lower frequency of oestrogen-receptor positive tumours and a lower proportion of hormone responsive tumours than women with SHBG levels at the top of the range. 4. Case/control studies in which growth rates are not taken into account may be difficult to interpret.

The permanent effect of reproductive events on blood prolactin levels and its relation to breast cancer risk: a population study of postmenopausal women

In each of two population-based studies conducted on the Island of Guernsey between 1967-1976 and 1977-1984, respectively, single specimens of blood were taken from over 5000 normal women. From these two studies there were 1173 and 946 postmenopausal women in whom blood prolactin was determined and multivariate analysis was used to establish the association between blood prolactin concentration and possible determinants of risk of breast cancer. Since prolactin levels were log-normally distributed these analyses were done on log-transformed data. The age at menarche or menopause, age at first or last childbirth, length of reproductive life (i.e. time from menarche to menopause) or post-menopausal life (i.e. time from menopause to time of blood sampling), contraceptive use and history of breast cancer were not significantly associated with blood prolactin concentration. Of significance were age, parity, time of blood sampling and assay drift. Ponderosity (Quetelet's Index) was positively associated with prolactin concentration and this was significant using a one-tail criterion. Women with a mammographic pattern designated DY by Wolfe had significantly higher prolactin levels than those with N1 patterns. However, the main finding to emerge was that after standardizing for all the other variables increasing parity was related to a step-wise reduction in blood prolactin levels. Since this had occurred in women who had had their last child up to 35 years previously it implies this effect is permanent. It could therefore be that the protective effect on breast cancer risk of multiparity and early first pregnancy could be mediated by such a life-long reduction in blood prolactin levels.

New lumps in the breast following conservation treatment for early breast cancer

A new lump in the breast following conservation treatment for early breast cancer may represent a recurrence of the disease or may be a benign lesion. Clinical evaluation of these lumps is often extremely difficult and, potentially, mammography would seem to be of great importance in the assessment. Between November 1981 and March 1986, 214 patients with operable breast cancers of 4 cm or less in diameter underwent conservative treatment. The conservation technique comprised synchronous excision of the primary tumour without a wide margin, axillary clearance, interstitial irradiation with iridium 192 (2000 cGy), and subsequent external beam radiotherapy to the breast (4600 cGy). After an average follow-up of 26 months, 17 patients developed a new lump in the treated breast necessitating further biopsy. Seven of these were malignant and 10 benign. In the latter category the most frequent finding was fat necrosis. Clinically, the lesions were indistinguishable from each other. The mammographic signs, which best predicted malignancy, were either of a mass or of a malignant type of microcalcification. This study illustrates the problems associated with deciding the nature of a new lump in the breast following conservation treatment. Mammography is complementary to physical examination, and a base-line mammogram six months after completion of therapy is helpful. Despite the use of mammography, biopsy is the only definitive way of excluding recurrence.

Assessment of skin dose and its relation to cosmesis in the conservative treatment of early breast cancer

A conservation technique has been developed for the treatment of early breast cancer which involved removal of the tumor, axillary clearance, tumor site implantation with Iridium-192 wires for a boost dose and subsequent treatment of the breast with radical megavoltage external beam therapy. Although the cosmetic results were satisfactory in the majority of the patients, for some it was rated as fair or poor. One variable factor which could have carried some morbidity was the dose of radiation received by the skin. In 51 patients, doses were measured at several points over the treated breast using Thermoluminescent Dosimetry (TLD) at the time of the iridium implant and during the subsequent external beam therapy. Development of skin pigmentation, oedema, and fibrosis were unrelated to the dose received by the skin but the findings suggested that doses greater than 50 Gy to the skin increased the possibility of late (greater than 24 months) telangiectasia over the boosted area. Treatment of tumors in the lower half of the breast, or in large breasts, was associated with a higher incidence of poor cosmesis. This may have been the result of varying posture on the interstitial dose distribution from the Iridium-192 wires and comparison of dose distribution in both supine and erect positions was carried out.

The relationship between blood prolactin levels and risk of breast cancer in premenopausal women

Single specimens of blood have been taken from over 5000 normal volunteer women in each of two sequential (1967-1976, 1977-1984) population-based studied on the Island of Guernsey. Multivariate analysis was used to determine the relationship between prolactin levels and risk factors in breast cancer in 2591 and 1959 premenopausal women in whom blood prolactin had been measured. In both populations the prolactin concentrations appeared to be log-normally distributed and therefore all analyses have been done on log-transformed data. Initially the variables in the statistical model were age at menarche, ages at first and last baby, parity, ponderosity (Quetelet Index), mammographic pattern (as graded by Wolfe), family history of breast cancer, age, menstrual cycle status, time of day of blood sampling, oral contraceptive use, history of breast feeding and methodological changes in the laboratory measurement of prolactin. Of these variables age at menarche, ages at first and last child and family history of breast cancer were found not to be significant and were excluded from the final model. The main finding to emerge was that after standardizing for all the other variables, prolactin levels in the follicular phase were significantly lower than those found at midcycle or during the luteal phase of the menstrual cycle. A peak level of prolactin was found at day 12 of the cycle. Increasing parity was related to a steady decrease in prolactin concentration. Increasing ponderosity was associated with an increased prolactin level as was a DY compared to an N1 mammographic pattern. Women with a history of oral contraceptive use had lowered prolactin concentration. All these effects occurred evenly over the menstrual cycle and were generally found for both data sets. Thus body weight, parity and, indirectly, age at first baby might influence breast cancer risk by being associated with changes in blood prolactin concentration.

A trial of human alpha interferon as an adjuvant agent in breast cancer after loco-regional recurrence

Thirty-two women who had developed loco-regional recurrence of breast carcinoma were entered into a controlled trial of adjuvant alpha-interferon. All patients had histological confirmation of recurrence, local treatment with radiotherapy and negative staging investigations. They were then randomized to either observation alone, or treatment with human alpha interferon 3 x 10(6) units subcutaneously daily for 1 year. There were no differences detected in the rate of local or distant relapse. With this lack of clinically significant efficacy and a high incidence of side effects, it is concluded that alpha interferon is of doubtful value in the adjuvant treatment of breast cancer.

Adjuvant androgen treatment of operable breast cancer--a 20 year analysis

One hundred and fifty-five patients with carcinoma of the breast treated by mastectomy were randomised to receive no additional treatment or to receive adjuvant testosterone. After a minimum follow up of 15 years there is no difference in either relapse free survival or overall survival between the treated and control groups. Stratification by pathological nodal status showed no benefit either for those with negative or positive axillary lymph node involvement.

Binding of oestradiol to blood proteins and aetiology of breast cancer

A prospective study of 5,000 women has shown that, compared to controls, those who subsequently developed breast cancer had a higher proportion of their blood oestradiol in the non-protein-bound and albumin-bound fractions (the bio-available fraction) and a lower proportion in the sex-hormone-bound fraction. The increased proportion of bio-available oestradiol was partly due to a lower concentration of sex-hormone-binding globulin. Weight was excluded as a confounding factor.

Thyroid function and the incidence of breast cancer in Hawaiian, British and Japanese women

Serum-free thyroxine (FT4) concentrations are lower in Hawaiian and Hawaiian Caucasian women than in Hawaiian Japanese, Hawaiian Filipino, Hawaiian Chinese, and English and Japanese mainland women. There is a high inverse correlation between FT4 and risk of breast cancer in these ethnic groups. Thyroid-stimulating hormone (TSH) concentrations, which are inversely correlated with FT4, generally show the same relationship.

In situ ductal carcinoma of the breast: implications of disease pattern and treatment

Ninety-seven patients with in situ ductal carcinoma (DCIS) of the breast have been reviewed. The commonest presenting feature was a breast lump, and residual carcinoma was found in the mastectomy specimen in 63% of patients. Furthermore, 13 cases had evidence of infiltrating carcinoma when the mastectomy specimen was examined. Thus excision alone would have left residual in situ or infiltrating carcinoma in two-thirds of the cases. A wide excision, by removing local residual disease, would still have left multifocal disease in one-third of cases. Studies need to be conducted to determine whether conservative treatment of DCIS can yield results which are as good as those following total mastectomy.

A comparison of intracavitary talc and tetracycline for the control of pleural effusions secondary to breast cancer

Forty-one patients with malignant pleural effusions secondary to breast cancer were randomly allocated to treatment with either intracavitary talc or intracavitary tetracycline. Of 33 evaluable patients, radiological control was achieved in 11/12 (92%) of the talc group compared with 10/21 (48%) of the tetracycline group (P = 0.022). Intracavitary talc provides effective palliation of metastatic pleural effusions secondary to breast cancer.

Effect of the method of biopsy on the prognosis of and reliability of receptor assays in patients with operable breast cancer

A comparison has been made of the survival of contemporary patients treated by mastectomy in whom the original diagnosis was made by either Tru-cut biopsy or by excision biopsy. After a minimum of 5 years of follow-up there was no difference in survival between those biopsied by either method. When subdivided by tumour size again no differences emerged. Among those patients in whom the original Tru-cut biopsy was false negative there was no difference in survival compared with those treated by excision biopsy. This suggests that Tru-cut biopsy is a safe method for obtaining a histological diagnosis in operable breast cancer. Furthermore, when the receptor status of the tumours from the two groups was determined, there was no difference in the percentage of oestrogen receptor positive tumours, nor in the mean receptor value. However, there were more progesterone receptor positive tumours among the Tru-cut group, suggesting that a better tumour sample could have been submitted for analysis. This may be yet another advantage for the use of Tru-cut biopsy for the diagnosis of breast cancer.

A prospective study of mammographic parenchymal patterns and risk of breast cancer

Breast parenchymal patterns have been assessed by the method of Wolfe in a prospective study in Guernsey. Women with P2 or DY grades had approximately four times the risk of developing breast cancer compared with those with N1 or P1 grades. Age, weight, parity and age at birth of first child are all related to the distribution of mammographic patterns. The combination of these variables with Wolfe grades may identify subsets of the population at very high risk.

Salivary oestradiol and progesterone levels in premenopausal women with breast cancer

The concentrations of oestradiol and progesterone have been measured in salivary specimens collected daily over a complete menstrual cycle in 12 patients with operable breast cancer and 12 normal control volunteers. There was no significant difference (P greater than 0.05) for either hormone between these two groups. Both showed a mid-cycle rise in oestradiol levels followed by a smaller but sustained increase during the luteal phase. The progesterone concentration increased markedly during the luteal phase of the cycle. Total or non-protein bound oestradiol levels measured in blood samples from 19 normal women were both linearly correlated (P less than 0.001) with the concentration of oestradiol in matched saliva samples. The amount of free oestradiol in blood was about twice that found in saliva.

Serum prolactin levels in women with breast cancer and their relationship to survival

Serum prolactin (HPr) has been measured in 459 patients 1 day before (HPr-1) and in 433 patients 10 days after (HPr-2) treatment. These came from an unselected sequence of 739 patients with operable breast cancer who had been referred to Guy's Hospital over a period of 5 yr. In addition HPr was measured in 100, or more, women at 3, 6 or 12 months after mastectomy. The median levels of either HPr-1 or HPr-2 were higher in pre-menopausal compared with postmenopausal patients (P = 0.03 and 0.06, respectively). Mastectomy was associated with increased serum HPr in both pre- and post-menopausal patients (P less than 0.001 in both cases). Average levels at 3 months, or after, were similar to those found before treatment. Nulliparous women had a higher median amount of HPr-1 than parous which was significant in premenopausal patients (P less than 0.008) whilst HPr-2 levels were not related to parity. Thus the rise in HPr associated with surgery was greater in parous than nulliparous women. Prolactin levels were not related to nodal status or tumour size. However, the amounts of HPR-2 were significantly greater in women with histological grade 3 tumours than those with grade 1 or 2. Standardising for either nodal status, tumour size or histological grade seven situations were found in which HPr-1 or HPr-2 levels were of prognostic significance. Although some of these significant associations could be fortuitous all shared a common feature that the least favourable prognosis was associated with the highest HPr levels.

The significance of supraclavicular fossa node recurrence after radical mastectomy

The clinical and pathologic features of 35 patients who had ipsilateral supraclavicular node (SCF) recurrence after radical mastectomy were reviewed. These were compared with the features of 70 patients who had a local skin recurrence after radical mastectomy, 48 of whom had a single nodule and 22 of whom had multiple skin nodules. There were no significant differences between age at diagnosis, disease-free interval, menstrual status, tumor type and grade, and extent and location of axillary node metastases in the three groups. Survival of the SCF group was intermediate between those of the single-nodule and multiple-nodule groups. SCF recurrence is an almost invariable signal of micrometastatic disease; thus, such patients are ideal candidates for trials of adjuvant therapy.

Double-blind controlled trial of tamoxifen therapy for mastalgia

60 patients with severe mastalgia of more than 6 months' duration were randomly selected for treatment with either tamoxifen 20 mg daily or placebo for 3 months. As measured by linear analogue scoring, pain relief was achieved in 22/31 (71%) of those receiving tamoxifen and 11/29 (38%) of those taking placebo. Patients who did not respond to the first course of treatment were allocated to the alternative treatment for 3 months. Pain control was achieved in 8/12 (75%) of those receiving tamoxifen and 2/6 (33%) of those receiving placebo. The commonest side-effects were hot flushes (27% of patients receiving tamoxifen and 11% of those receiving placebo) and vaginal discharge (17% tamoxifen, 7% placebo). Side-effects caused 6 patients in each group to discontinue treatment. Tamoxifen is of value in the management of severe cyclical and non-cyclical mastalgia, and relief can be achieved without undue side-effects in the majority of patients.

Sensory changes after treatment of operable breast cancer

A study has been conducted to compare the nature and severity of post-operative sensory changes (sensory loss, paraesthesiae, and pain) among patients with breast cancer treated by either modified radical mastectomy or a conservative procedure (tumourectomy, axillary clearance, iridium implant, and external radiotherapy). There was a similar incidence of post-operative sensory loss in the two groups, reported by 82% of the mastectomy group and 77% of the iridium group, and an equivalent rate of improvement (76 and 80% respectively). Post-operative paraesthesiae occurred in 61% of the mastectomy group and 63% of the iridium group; maximum severity of paraesthesiae was similar as was the percentage improving. Among the mastectomy group 55% reported phantom breast sensation and 61% of the iridium group had post-operative breast pain. Improvement occurred in 58% of those with breast pain. These findings may have implications for the counseling of patients with breast cancer who are going to be treated by certain conservative procedures.

Influence of reproductive history on age at diagnosis of breast cancer and prognosis

The effect on age at breast cancer diagnosis of age at menarche, age at first baby, parity and age at menopause has been determined for 739 unselected patients diagnosed between 1975 and 1980 as having operable breast cancer. Age at diagnosis was significantly and positively associated with ages at menarche, first baby and menopause. The average number of children significantly declined with increasing age at diagnosis. This was largely due to a change in the proportion of patients who were nulliparous (15% in women aged 41-50 years compared to about 30% in those over 60 years). A group of 1,989 normal women whose reproductive history was also collected between 1975 and 1980 showed similar trends between age and age at menarche, age at first baby and parity as the patients. Thus it appears that these reproductive parameters do not alter the time of onset of breast cancer but could be explained by temporal changes in reproductive patterns. There was no significant correlation between age at menopause and age at diagnosis for patients whose age at menopause was no more than 54 years and age at diagnosis no less than 55 years, respectively. It is therefore unlikely that age at menopause affects age at diagnosis. Postmenopausal patients with 3 or more children had a significantly shorter disease-free interval and lower survival rate than those with less children. None of the other parameters was associated with prognosis.

Family history and bilateral primary breast cancer

The prevalence of a family history of breast cancer was established in 54 women with bilateral primary breast cancer and 208 women with unilateral disease. Women with bilateral disease had significantly greater prevalence of family history than women with unilateral breast cancer (P less than 0.01). Compared with the unilateral cancers, a significantly greater proportion of bilateral cancers had first degree affected relatives (P less than 0.05). Moreover the affected relatives of probands with bilateral disease showed a significantly higher prevalence of bilateral breast cancer compared with the relatives of women with unilateral disease (P = 0.04). The findings suggested that bilateral disease was a characteristic of familial breast cancer.

Optimal surgical approaches to the local management of early breast cancer. A panel discussion

In recent years, a trend has developed toward more conservative surgery for early breast cancer, often in combination with axillary dissection or sampling and with radiotherapy. Here, three prominent breast cancer surgeons discuss the proper role of these procedures and several areas of contention concerning them.