The diagnostic value of testing for occult blood

An analysis of 270 patients undergoing microdochectomy for nipple discharge from a single identifiable duct, and without an associated lump, revealed that occult cancers were all accompanied by hemoglobin positive discharge. A simple method of detecting the presence of hemoglobin in the discharge is described. The incidence of cancer was found to be 5.9%. In order of frequency, intraduct papilloma, duct ectasia, cystic disease, and carcinoma accounted for over 90% of the cases. Six patients in whom no malignancy was seen in the microdochectomy specimen subsequently developed cancer in the ipsilateral breast. A close follow-up of all patients with hemoglobin positive discharge and in whom no cause for the discharge is demonstrated at microdochectomy is stressed.

Contribution of prednisolone to the primary endocrine treatment of advanced breast cancer

Two hundred and four patients with progressive locally advanced or metastatic breast cancer not controllable by local therapy alone, and who had had no prior systemic therapy for advanced disease, were treated by primary endocrine therapy according to menopausal status. Premenopausal patients received ovarian irradiation (O) whilst postmenopausal patients received tamoxifen 10 mg b.d. (T). Patients were randomised to receive either no additional treatment or prednisolone 5 mg b.d. (P). In 180 evaluable patients, T + P induced significantly more responses than T alone (26/73 vs 9/72, P less than 0.01) and the addition of P to O in premenopausal patients also induced more responses than O alone (7/16 vs 4/19), but this difference was not significant and accrual of premenopausal patients continues. There was a trend for patients receiving T + P to have a longer survival than those receiving T alone (median 25 vs 16 months). These trends occurred in patients with tumours positive for oestrogen receptors and when receptor status was unknown; patients with receptor-negative tumours had a negligible response to endocrine treatment. P mitigated the occurrence of hypercalcaemia and tumour flare sometimes seen with T alone.

Oestrogen receptors, clinical features and prognosis in stage III breast cancer

One hundred and twenty-four patients with stage III breast cancer who had oestrogen receptor analyses (ER) performed on primary tumour were studied. For operable disease (T3a, N0.1, M0), patients with ER-negative (ER less than 5 fmol/mg cytosol protein) tumours had a shorter duration of symptoms, but no other differences were observed at presentation. In patients with inoperable (T3b,4, N0.1, M0 or any T, N2.3, M0) tumours there were no differences in the clinical characteristics that rendered the primary tumour inoperable between those with ER+ or ER- tumours. The median disease-free interval (DFI) in patients with operable tumours and uninvolved axillary nodes was significantly longer in those with ER+ tumours (P less than 0.05). Median survival was significantly longer in patients with ER+ tumours than in those with ER- tumours (50 vs 27.5 months, P less than 0.05), and when survival was analysed according to various methods of initial treatment, it was significantly prolonged in patients with operable (T3a, N0.1, M0) ER+ tumours compared to those with operable ER- tumours. In patients with inoperable tumours no effect of ER status on prognosis was demonstrated. These results suggest that oestrogen receptor content may be a prognostic variable in patients with operable stage III breast cancer, but further studies of patients with similar methods of initial treatment are needed to confirm this. Patients with operable stage III tumours should be considered separately from those with locally advanced inoperable tumours in view of the significant differences in their survival prospects.

The response to endocrine therapy in patients with advanced breast cancer in Great Britain and Japan

A prospective study has been carried out to compare the response rates to endocrine therapy of Japanese and British women with breast cancer. Premenopausal women were treated by ovarian ablation, patients who were up to five years postmenopausal were prescribed androgen therapy and patients who were more than five years postmenopausal were treated with oestrogens. No differences in response rate, response time or survival could be detected in the three categories of patients. Significantly more Japanese patients presented with pulmonary metastases in the pre- and postmenopausal groups. In postmenopausal Japanese patients treated with oestrogens, those with pulmonary metastases survived significantly longer.

Urinary androgen metabolites and recurrence rates in early breast cancer

Androsterone and aetiocholanolone were measured in urine specimens obtained from 218 women with early breast cancer. Patients who excreted less than the median amount of these steroids had a significantly higher recurrence rate (P less than 0.005) than patients excreting more than the median value. The relationship between androgen excretion and recurrence is stronger in pre-menopausal women that in the post-menopausal group. The androgen assays are still associated with recurrence rates when patients are stratified by pathological stage, but no clear relationship was found with histological grade.

The pattern of metastatic disease in patients with pleural effusions secondary to breast cancer

The pattern of pleural metastases in women with effusions secondary to breast cancer was evaluated by thoracoscopy in a series of 46 patients with previously untreated effusions. Metastases involving the visceral pleural were seen in 59 per cent of patients whereas parietal deposits were found in only 15 per cent. No tumour deposits were seen in 26 per cent of cases. No patients had both visceral and parietal tumour secondaries. Patients within each of these groups showed differences in rates of positive effusion cytology, chest wall recurrence and previous evidence of recurrent breast cancer.

Serum concentrations of total and non-protein-bound oestradiol in patients with breast cancer and in normal controls

In premenopausal women with breast cancer, total serum oestradiol (E2) concentrations are normal but nonprotein-bound E2 concentration are significantly raised. This is not due to low sex-hormone-binding-globulin (SHBG) binding capacities which are within the normal range and is unlikely to be due to the small but significant decrease in albumin concentrations. In post-menopausal patients, both total and non-protein-bound E2 are significantly raised: this may be explained partially by lower SHBG binding capacities. In patients and controls there is a highly significant correlation between non-protein-bound E2 and SHBG but, for a given SHBG binding capacity, the patients have more non-bound E2 than controls. It is concluded that the breast in women with breast cancer may be exposed to elevated levels of biologically active E2 although the reasons for this remain obscure.

The relation between radiological patterns of the breast and body weight and height

Mammograms were obtained from 942 normal volunteer women aged over 35 years, and were classified by Wolfe's criteria. There was no relationship between height and mammographic pattern. An increase in weight, whether corrected for height or not, was associated with an increase in the proportion of N grades and a concomitant decrease in DY grade mammograms. This effect reached formal significance in pre-menopausal women but was highly significant in post-menopausal women. For women who were either above or below their ideal weight there was a significant positive correlation between parity and the proportion of N and P1 mammograms. The slopes of the linear regression for these two groups were the same, although the elevation of the above-ideal weight group was significantly greater. This implies that for any given parity, there are about 16% more N or P1 grades in the above-ideal compared with the below-ideal weight group.

A prospective study of plasma prolactin levels and subsequent risk of breast cancer

Plasma prolactin was measured in 2,572 pre-menopausal, 628 menopausal, and 1,666 peri- and post-menopausal women who were apparently healthy. Breast cancer was subsequently diagnosed in 47 of these women at a median time of 5 years after blood collection (pre-cancer cases). Prolactin levels in pre-menopausal cases increased significantly with age whereas this was not found in matched controls. The perimenopausal cases were characterized by extreme variability in prolactin levels. In post-menopausal women who developed breast cancer, the prolactin levels were significantly elevated, being at or above the 70th percentile for the controls. In this group the results are consistent with prolactin acting as a late-stage tumour promoter.

Corticosteroids for elderly patients with breast cancer

Ninety-one assessable elderly women (greater than 65 years) with advanced breast cancer were treated with prednisolone 15 mg (or cortisone 75 mg) daily after primary endocrine treatment (estrogens, androgens or tamoxifen). Thirteen (14%) achieved an objective regression, and 19 (21%) others showed no change for greater than or equal to six months. Hence, 32 patients (35%) had control of disease for about one year. Responses were mainly in soft tissue and skeletal lesions and were independent of response to prior endocrine treatment. Toxicity was low. Low-dose corticosteroid treatment is of value in controlling advanced breast cancer in elderly women.

Clinical estimation of the growth rate of breast cancer

To test the ability of the patient's history to provide prognostically important information in breast cancer the authors used information prospectively collected by interview from 756 patients enrolled in a randomized controlled trial of adjuvant therapy. Classification of this information according to the principles of rate of growth created groups with substantial and statistically significant differences in survival. The survival differences created by classifying growth rate were comparable to those created by other prognostic factors, and independent of those created by stage, lymph node status or tumor grade. The patient's history in breast cancer is capable of providing reproducible prognostic information when it is suitable classified, and this information represents a useful addition to current methods of estimating prognosis in breast cancer.

Plasma prolactin levels and breast cancer: relation to parity, weight and height, and age at first birth

Plasma prolactin has been measured in over 3,500 women volunteers from a normal population. In premenopausal women there was a significant decrease in prolactin levels with increasing parity. However, this effect was transitory since plasma prolactin concentration rose with increasing time after the birth of the last child. There were no significant differences in prolactin levels with respect to height and weight, although overweight compared to underweight women had approximately 15% more plasma prolactin. If prolactin is a carcinogen, then these results are in keeping with the epidemiological findings that multiparity affords protection and that age at last delivery is a risk factor in the development of breast cancer.

Surgical approaches to the treatment of early breast cancer

Various methods have been explored for treating early breast cancer with conservation of the breast. Although local recurrence increased, early trials indicated that in patients with clinical stage I disease (T1 or T2 NO or N1a), wide excision and radiotherapy of the breast and gland fields resulted in the same distant recurrence and survival rates as the radical operation. It was suggested that local control of the disease was not important in the ultimate prognosis, that minimal surgery incurred no penalty and that breast cancer would soon be treated by radiotherapy alone. Four recent developments affected this forecast. 1. Assays of hormone receptors in primary tumours give important information on prognosis in early cancer. 2. In clinical stage II disease (T1 or T2 N1b), limited surgery exacts a penalty in terms of distant recurrence and survival. 3. The number in involved axillary lymph nodes must be known to evaluate prognosis 4. Adjuvant chemo- or endocrine therapy is effective in patients with extensive involvement of axillary nodes. Currently, only modified radical mastectomy effectively fulfils the requirements resulting from these developments.

Pleural effusion in breast cancer: a review of 105 cases

This paper reviews 105 patients with breast cancer who had a pleural effusion as a direct consequence of metastatic disease. The mean lag time between diagnosis of primary tumor and presentation of the effusion was 41.5 months. Mean survival time after development of an effusion was 15.7 months. Of the 99 patients with unilateral breast tumors, 50% had ipsilateral effusions, 40% were contralateral, and 10% were bilateral. Forty-two percent of the patients had pleural effusion as the first evidence of recurrence. No particular group of women, based on age, menopausal status, or parity could be identified as being at risk of developing a subsequent effusion. However, there was a significantly higher proportion of patients who had central and medial tumors and who had Stage III cancers. Other tumor features, such as size, histologic type, or grade, did not predict the development of pleural metastasis. The success rate of a variety of treatment methods, local, general, or a combination of both, was 17% in achieving control of effusions. There may be a place for more aggressive treatment of pleural effusion at first presentation so that the quality of life could be improved during the patient's remaining months of survival.

Breast cancer in women who have taken contraceptive steroids

The prognosis and clinical and pathological findings in 93 patients with breast cancer who had taken contraceptive steroids before diagnosis (study group) were compared with those in 93 control patients, also with breast cancer, matched for age and parity. The tumours in the women in the study group were found to have more favourable clinical and histological features than those in the control group. When only patients who had been treated by radical mastectomy were considered, those who had taken contraceptive steroids survived significantly longer even when differences in nodal state were taken into account. Significantly more patients in the study group had a family history of breast cancer. No evidence was found that taken oral contraceptive steroids had any harmful effect on tumour growth and spread, except possibly in patients with a close family history of breast cancer.

Estrogen receptors and response to endocrine therapy and cytotoxic chemotherapy in advanced breast cancer

In a consecutive series of 191 patients with advanced breast cancer, the response rate to endocrine treatment was 46/136 (34%) in estrogen receptor positive (ER+) patients, compared with 5/55 (9%) in estrogen receptor negative (ER-) patients (P < 0.01). In a retrospective analysis of 47 patients, the response rate to cytotoxic chemotherapy was 20/33 (62%) for ER+ tumors and 8/14 (57%) for ER-. It is concluded that ER+ tumors have a significantly higher chance of responding to endocrine therapy than do ER- tumors, but that receptor status is not a determinant of response to cytotoxic chemotherapy.

Assessment of axillary lymph node status

Three methods of assessing axillary lymph node status were compared: In 149 patients assessed clinically, positive nodes were not detected in 31 (45%) of 69 patients with pathologic Stage II disease. Histologic examination of selected axillary nodes biopsied from 54 patients immediately prior to mastectomy, failed to detect metastatic disease in 11 (42%) of 26 patients with pathologic Stage II disease. Examination of lymph nodes in the axillary tail of 95 mastectomy specimens failed to diagnose axillary involvement in six (14%) of 43 patients with pathologic Stage II disease. Thus, none of the techniques determined the extent of axillary node involvement.

Value of needle biopsy in outpatient diagnosis of breast cancer

Outpatient needle biopsy of suspected breast cancers has been performed on 151 patients. Of 135 who were ultimately diagnosed as having a malignant tumor, 107 were correctly diagnosed on the initial needle biopsy, a success rate of 79%. The procedure is well tolerated by most patients and enables family support during a very stressful period. Furthermore, outpatient histopathologic confirmation of cancer allows adequate preoperative investigation and more efficient use of operating theater time.

Oestrogen receptors and response to cytotoxic chemotherapy in advanced breast cancer

Of 54 patients with advanced breast cancer, 21/37 (57%) with oestrogen receptor-positive (ER+) tumours and 11/17 (65%) with oestrogen receptor-negative (ER-) tumours responded to cytotoxic chemotherapy. These data and a survey of the literature indicate that oestrogen receptor status is not a determinant of response to chemotherapy. However, ER+ tumours seem to grow more slowly than ER- ones and the response to chemotherapy tends to be longer in ER+ patients.