Survival following local skin recurrence after mastectomy

Seventy-three patients with breast cancer, treated by radical mastectomy, who subsequently developed a local skin recurrence without clinical evidence of disseminated disease, have been reviewed. There were significant differences between the survival of patients with single and multiple recurrences. Only 10 per cent of those with multiple lesions survived 5 years, and none was alive at 10 years, whereas 42 per cent of those with single lesions survived 5 years and 22 per cent were alive and well at 10 years' postrecurrence. Adequate local treatment of a single skin nodule may enable a subset of patients to survive without subsequent development of breast cancer metastases.

Which patients are cured of breast cancer?

The clinical and pathological features of 51 patients who survived for more than 20 years after diagnosis of cancer of the breast were compared with those of 176 contemporaries who died within 20 years after diagnosis. Of those who survived, 18 (35%) had had pathologically affected axillary nodes compared with at least 86 (49%) of those who died. Also, 11 (21%) of the survivors had had small tumours compared with 10 (6%) of those who died. Pathological review of tumours in the survivors showed 40 (78%) to have been infiltrating ductal carcinomas, of which 13 (32%) were grade 3 lesions. These differences between the two groups were largely due to the prognostic value of these variables in the first five years after diagnosis. After a patient had survived five years the major prognostic variables were of little value in the prediction of which patients would be cured of breast cancer. Advanced age, which was of little prognostic value in the first five years after diagnosis, was of significant prognostic value in the longer term, partly due to the steep age gradient for mortality from other diseases. Nevertheless, seven of 19 deaths more than 20 years after first treatment were due to breast cancer. Late deaths from breast cancer may, however, have often been the result of metastases from second primaries rather than the late manifestation of micrometastases from the original primary carcinoma. Age, menstrual state, clinical stage, and axillary nodes being affected are thus of some prognostic value in cancer of the breast, but the present inadequacy of knowledge of the behaviour of the disease makes accurate prediction of which patients will be cured impossible.

Bilateral primary breast cancer: a prospective study of disease incidence

A prospective study was carried out, between January 1980 and March 1982, of all women who presented to the Breast Cancer Unit, Guy's Hospital, with a second primary breast cancer. The percentage of new simultaneous tumours detected clinically or by mammography was approximately 3 per cent. Routine mammographic screening of the contralateral breasts of patients with unilateral disease increased the rate of detection, fivefold, of simultaneous bilateral cancers. The incidence of nonsimultaneous bilateral disease was 7.6 second cancers per thousand patients at risk per year. The annual rate of occurrence of second primary cancers was a constant event and showed no trend either to increase or to decrease with follow-up. However, the risk of a nonsimultaneous second cancer was strongly correlated with age at first primary. Women who developed their first breast cancers under the age of 40 years had three times the risk of developing a second breast cancer compared with those who developed their first cancer after the age of 40. The risk of a second nonsimultaneous primary was 5.9 times that of the risk of occurrence of cancer in the first breast in the general female population.

Controlled trial of adjuvant chemotherapy with cyclophosphamide, methotrexate, and fluorouracil for breast cancer

327 patients with cancer of the breast and involvement of axillary lymph nodes were randomised, after total mastectomy and axillary clearance, to receive either no additional treatment or oral cyclophosphamide 80 mg/m2 on days 1-14, intravenous methotrexate 32 mg/m2 on days 1 and 8, and intravenous fluorouracil 480 mg/m2 on days 1 and 8 (CMF), which was repeated every 28 days for twelve cycles. There was a significantly longer relapse-free survival (RFS) in patients treated with CMF. A prolonged RFS was seen in premenopausal patients, those with 1-3 nodes involved, and those with 4 or more nodes involved, but a similar trend in postmenopausal patients failed to reach statistical significance. RFS was greater in patients with CMF-induced amenorrhoea than in controls and in treated patients whose primary tumour contained progesterone receptors. Dose of chemotherapy did not have a significant effect on RFS. Survival was not influenced by treatment.

Norethisterone acetate in the treatment of advanced breast cancer

One hundred and twenty-five patients with progressive advanced carcinoma of the breast were treated with norethisterone acetate 20 mg tds orally after prior hormonal treatment or chemotherapy. Ninety-nine patients are evaluable for response. Sixteen patients (16%) achieved a partial response (median duration 4.5 months), 26 (26%) had stable disease (median duration 3 months) and 57 (58%) developed progressive disease on treatment. Patients who responded to norethisterone acetate had more often responded to prior hormonal or ablative treatment (56% vs 25%) and had received less prior treatment than those who did not respond (p less than 0.05). There was no statistically significant correlation between response and age, menopausal status, disease-free interval, stage at diagnosis, or distribution of disease. Side effects led to cessation of therapy in nine patients (9%).

Nyctohemeral changes in plasma prolactin levels and their relationship to breast cancer risk

The amount of prolactin has been determined in serial blood samples taken over 24 h from 20 pre- and 9 postmenopausal women volunteers. All women had a large increase in prolactin at night (24.00 h-03.00 h). A much smaller rise in prolactin occurred in the evening (18.00 h-20.00 h) which was just significantly different (p less than 0.05) from levels found in the afternoon. Prolactin concentrations at any given time in the 29 women were linearly correlated with corresponding levels in either of the adjacent time intervals. This correlation was highly significant (p less than 0.001) throughout 24 h, implying that a woman with a relatively high (or low) blood prolactin in the afternoon would have a similarly high (or low) concentration in the evening or at night. Premenopausal women had higher amounts of prolactin than postmenopausal volunteers throughout the day. Parity was found to be inversely related to prolactin levels in pre- and postmenopausal women; this effect was especially marked in the night peak of prolactin. In postmenopausal women an average of 33 years had elapsed since the birth of the last child, which implies that childbirth has a life-long effect on reducing prolactin levels. Thus the protective effect of early child-bearing and multiparity against developing breast cancer could be at least partly explained by these effects on serum prolactin levels.

Urinary androgen and 17-hydroxylated corticosteroid metabolites and their relation to recurrence rates in early breast cancer

The amounts of urinary androsterone and etiocholanolone are highly correlated with recurrence rates in patients with early breast cancer after treatment by mastectomy. A more efficient means of predicting the clinical course of the disease is obtained by using a ratio of these compounds to the amounts of individual 17-hydroxycorticosteroids in the urine. For instance, the ratio of androsterone to alpha-cortolone is particularly effective in identifying women with a high rate of recurrence, and this is largely independent of pathological stage and tumor grade.

A new combined approach to the conservative treatment of early breast cancer

A combined surgical and radiotherapeutic technique is described that aims to: (1) achieve permanent local control of disease; (2) give full information on the histology and biochemistry of the tumor; (3) detail axillary node status; and (4) be compatible with adjuvant endocrine therapy or chemotherapy. This treatment is accomplished with minimal cosmetic defect and, in the majority of patients, with almost total conservation of the breast form. The surgical procedures are carried out during one hospital admission and performed with one anesthetic. No prosthetic replacement or augmentation of the breast is involved.

Plasma retinol, beta-carotene and vitamin E levels in relation to the future risk of breast cancer

In a prospective study of 5,004 women in Guernsey, plasma samples were collected and stored. Retinol, beta-carotene and vitamin E levels were later measured in the samples from 39 women who subsequently developed breast cancer and from 78 controls who did not develop cancer. Plasma retinol levels were not related to the risk of breast cancer, mean levels among cases and controls being 485 micrograms l-1 and 479 micrograms l-1 respectively. Plasma vitamin E levels showed a clear association, low levels being associated with a significantly higher risk of cancer. The mean vitamin E levels among cases and controls were 4.7 mg l-1 and 6.0 mg l-1 respectively (P less than 0.025), and the risk of breast cancer in women with vitamin E levels in the lowest quintile was about 5-times higher than the risk for women with levels in the highest quintile (P less than 0.01). beta-carotene levels showed a tendency to be lower in women who developed cancer than in controls (36 micrograms l-1 among cases compared with 50 micrograms l-1 among controls) but the difference was not statistically significant.

Urinary hydroxyproline and prognosis in human breast cancer

The excretion of urinary hydroxyproline has been measured before mastectomy in 342 patients presenting with breast cancer for the first time to Guy's Hospital. The first 106 women were maintained on a gelatine-free diet whilst the remainder were on unrestricted diet. In both dietary groups hydroxyproline levels or the ratio of hydroxyproline to urinary creatinine were not related to pathological stage or histological grade. The time between initial presentation and subsequent bone metastases was negatively and significantly associated with hydroxyproline excretion (P less than 0.05) and the ratio of hydroxyproline to creatinine (P less than 0.01) in women on a gelatine-free diet. A similar, but not significant, trend was observed in patients on unrestricted diet. Although hydroxyproline excretion was related to the time to onset of bone metastases the amount of hydroxyproline excreted by these patients was not significantly different from patients who had recurrences at sites other than bone or patients who were disease-free up to 5 years after initial diagnosis. The conclusion is that hydroxyproline is of little value in the early detection of bone metastases.

Serum carcinoembryonic antigen in the diagnosis and prognosis of women with breast cancer

Serum carcinoembryonic antigen (CEA) has been measured in 628 patients before and 577 patients after treatment for breast cancer. These came from an unselected sequence of 730 women, subsequently diagnosed as having stage I or II breast cancer, referred to Guy's Hospital over a period of nearly 5 yr. CEA was also measured in serum from 238 ostensibly healthy volunteers and 65 women with benign breast disease. CEA measurements were of no diagnostic value. There were more patients with breast cancer with values in excess of 10 ng/ml measured preoperatively (7%) or after mastectomy (5%) than in controls (3%), but the difference is of marginal significance. High levels of CEA were not consistently associated with pathological stage or histological grade. Mastectomy was not associated with any significant change in the distribution of CEA levels. Patients with stage II disease and pre-operative CEA levels over 10 ng/ml has a faster recurrence rate than those with levels of less than 2.5 ng/ml. High levels were also associated with reduced survival. However, such patients comprised about 5% of women presenting with early breast cancer, so that the use of CEA measurements for prognosis is of limited value.

A prospective study of urinary androgen levels and ovarian cancer

The three major urinary androgen metabolites, dehydroepiandrosterone (DHEA), androsterone (ANDRO), and aetiocholanolone (AETIO) were measured in 1,484 volunteer women between 29 and 60 years of age on the island of Guernsey from 1962-1967. Twelve of these women subsequently developed ovarian cancer after a median interval of 130 months and a minimum interval of 19 months. All three androgen levels in these women were lower than those in controls matched for age and menopausal status. The results were most striking for DHEA, where half of the cases were below the 27th percentile of their matched controls (p = 0.007, two-sided). The results for ANDRO were of marginal significance (p = 0.06), and those for AETIO were not significant (p = 0.33).

Steroid receptors and prognosis in operable (stage I and II) breast cancer

Four hundred and forty-seven women with operable (TNM stage I or II) breast cancer in whom oestrogen receptors (ER), progesterone receptors (PgR) or both receptors had been assayed were studied. Receptor status was independent of axillary nodal status, but infiltrating duct carcinomas that were ER-, PgR- or ER-PgR- were more likely to be anaplastic (P less than 0.001). Four hundred patients with follow-up and uniform treatment were analysed for post-operative disease-free interval (DFI) and survival. No significant difference in DFI existed between patients with ER+ and ER- tumours or PgR+ and PgR- tumours, although there was a trend for longer DFI for ER+ and PgR+. DFI was longer in patients with better-differentiated (grade 1 and 2) tumours than with anaplastic (grade 3) tumours. In patients with ER+ tumours, those with grade 1 and 2 tumours had a longer DFI than those with grade 3 tumours (P less than 0.005). Survival was significantly longer in patients with ER+ tumours compared to those with ER- tumours (P less than 0.001), but there was no such association between tumour PgR and survival. Survival of patients with ER+PgR+ tumours was significantly longer than those with ER-PgR- tumours (P less than 0.025) and, in patients with no evidence of axillary nodal involvement, significantly longer than those with ER+PgR- tumours. Survival in patients with nodal involvement was influenced by histological grade, being longer in those with grade 1 or 2 tumours compared to those with grade 3 tumours. For ER+ tumours, survival was longer in patients with grade 1 or 2 than with grade 3 tumours. These results suggest that steroid receptors significantly affect survival but not DFI. This effect is most closely related to ER content, with relatively little additional information accruing from analysis of PgR. Histological grade influences both DFI and survival, and analysis of both grade and ER content may give a more accurate indication of prognosis in operable breast cancer.

Breast parenchymal patterns in women with bilateral primary breast cancer

Mammograms were obtained from 44 women aged over 30 years with bilateral primary breast cancer, 60 women with unilateral breast cancer, matched for age and menopausal status with the bilateral cases, and 937 normal women, again all aged over 30 years. The mammograms were classified according to Wolfe's criteria. Both groups of cancer patients were found to have a significantly (p less than 0.05) greater proportion of pre-menopausal women with the DY type of breast parenchymal pattern compared with the normal pre-menopausal women. No association was found between the P2 mammographic pattern and breast cancer. The study failed to show any difference in the distribution of mammographic risk categories in women with bilateral disease and those with unilateral cancers only.

Distribution of 17 beta-estradiol in the sera of normal British and Japanese women

Normal Japanese women had significantly more of their blood 17 beta-estradiol (E2) bound to sex hormone-binding globulin (SHBG) (53%) than British women (30%) and conversely less bound to albumin. While the proportion of SHBG-bound E2 increased with SHBG capacity and while binding fell as weight increased, the differences between the races do not appear to be explicable in terms of SHBG capacity or weight. At a given SHBG capacity, the Japanese women had more E2 bound to the protein than the British women. Where weights in the 2 populations overlapped, the Japanese women still had more of their E2 bound to SHBG than did the British women. Our results suggested that the affinity of albumin for E2 is lower in Japanese women.

Thyroid function in early breast cancer

Serum 'free thyroxine' was measured as a thyroid function index (TFI) in 238 women with early breast cancer and 107 normal controls. The mean TFI was significantly lower in the cases compared with controls. The TFI was not related to pathological stage but correlated with histological grade, with the highest values found in well-differentiated (grade I) and the lowest in anaplastic tumours (grade III). A similar result was obtained with the urinary and androsterone:aetiocholanolone (5 alpha:5 beta) ratio in that the ratio was significantly lower in patients with grade III than in those with grade I tumours. These results indicate that thyroid hormones may be involved in tumour cell differentiation. Patients with low 5 alpha/5 beta ratios had significantly faster recurrence rates than those with high ratios. A similar trend was found for the TFI. The TFI decreases after mastectomy and at 12 months after operation is still below the pre-operative basal level.

Sequential bone scans and chest radiographs in the postoperative management of early breast cancer

A total of 241 patients with early breast cancer had serial bone scans and chest radiographs during the first two years of follow-up after primary treatment. Each patient had had a modified radical mastectomy and been found to have involved axillary nodes. They were part of a prospective randomized trial testing the use of L-phenylalanine mustard L-PAM as adjuvant chemotherapy. During the two years, these patients had a total of 832 serial bone scans and 1091 serial chest radiographs. Twenty-five patients (10.4 per cent) had bone metastases detected on sequential scanning, only 13 of whom, however, were asymptomatic at the time of the positive scan. Twelve (5 per cent) patients were found to have pulmonary metastases on routine sequential chest radiography of whom only 8 were asymptomatic at the time of the positive chest radiograph. It is concluded from this study that, apart from their usefulness in the monitoring of clinical trials, serial bone scans and chest radiographs cannot be recommended routinely in the follow-up of asymptomatic patients because of the low yield and high cost involved.

Control of pleural effusions in patients with breast cancer. A randomized trial

In a controlled randomized trial, 46 patients with pleural effusions secondary to breast cancer were treated at first diagnosis with either intracavitary mustine or talc, to determine which agent produced the more effective pleurodesis. Of the 37 evaluable patients, control of the effusion was achieved in 9/17 (56%) of those treated with mustine and 18/20 (90%) of the talc group (P less than 0.025). This suggests that early treatment with intracavitary talc can effectively palliate this complication of breast cancer.

Pathology of primary tumors and axillary lymph nodes in British and Japanese women with breast cancer

Histopathologic features of the primary tumor and axillary lymph nodes from 97 consecutive patients with breast cancer from Japan were compared with those from 164 patients from England. Between the two groups, there were statistically significant differences in the morphology of the primary tumors regarding nuclear grade and patterns of tumor infiltration. In axillary lymph nodes, sinus histiocytosis was much more common in Japanese cases than in British cases, and was related to a diminished frequency of axillary node metastases. Germinal centers were also more common in the nodes of Japanese patients and were similarly associated with diminished frequency of metastases.

Controlled trial of adjuvant chemotherapy with melphalan for breast cancer

370 patients who had carcinoma of the breast with involved axillary lymph-nodes were randomised after total mastectomy and axillary clearance to receive either no additional treatment or melphalan 6 mg/m2 daily for 5 days every 6 weeks for sixteen cycles. There was a trend towards longer relapse-free survival (RFS) in patients treated with melphalan, but this was not significant either in the whole series or in sub-groups according to menopausal status or extent of nodal involvement. In patients receiving melphalan RFS was not significantly affected by either the occurrence of amenorrhoea or the dosage of melphalan received. Overall survival did not differ significantly between the two groups. The results of this trial suggest that there is no place for the use of melphalan as adjuvant therapy in the management of early breast cancer.