Extended breast cancer treatment with an aromatase inhibitor (Letrozole) after tamoxifen: why, who and how long?

[Male breast cancer in Morocco: Epidemiology and prognostic factors. A report of 140 cases]

OBJECTIVES

Male breast cancer is rare; it constitutes 0.2-1.5 % of all malignant tumors in men and 1 % of all breast cancers.

METHODS

The goal of this retrospective study is to analyze the epidemiologic, clinic, therapeutic and evolutive profiles of this disease in 140 cases collected at the National Institute of Oncology and military hospital in Rabat, Morocco, between the years 1998 and 2007.

RESULTS

The mean age was 61 years. A high incidence of overweight was found. The most frequent clinical presentation was a firm subareolar lump in 83 % of cases. The most common pathological type was an infiltrating ductal carcinoma (93 %). Hormone receptors were positive in 86 % of cases. Eighty-five percent of patients underwent simple mastectomy and axillary dissection, 68 % chest wall irradiation after surgery, 54 % received chemotherapy and 82 % hormonal therapy. Median follow-up was 91.1 months. The estimated 5-year and 10-year overall survival was respectively 68 % and 74 %.

CONCLUSION

The management of male and female breast carcinoma is the same, as well as their prognosis at equal stages. Future research for better understanding of this disease are needed to improve the management and prognosis of male patients.

Meta-analysis of clodronate and breast cancer survival

Clinical trials have reported conflicting results on whether oral clodronate therapy improves survival in breast cancer patients. This study was undertaken to evaluate further the effect of oral clodronate therapy on overall survival, bone metastasis-free survival and nonskeletal metastasis-free survival among breast cancer patients. An extensive literature search was undertaken for the period 1966 to July 2006 to identify clinical trials examining survival in breast cancer patients who received 2 or 3 years of oral clodronate therapy at 1600 mg day(-1) compared with those without therapy. Meta-analyses were carried out separately for patients diagnosed with advanced breast cancer and early breast cancer. Our meta-analysis found no evidence of any statistically significant difference in overall survival, bone metastasis-free survival or nonskeletal metastasis-free survival in advanced breast cancer patients receiving clodronate therapy or early breast cancer patients receiving adjuvant clodronate treatment compared with those who did not receive any active treatment.

[Breast cancer in men]

Breast cancer in men is rare and most often occurs at or after the age of 60 years. Prognosis is poor when it is discovered at a late stage, as it often is in men, although it should be easier to detect because men have so little breast tissue. The causal mechanism appears to depend on hormone metabolism abnormalities related to elevated estrogen or prolactin levels. A family history of breast cancer is found in 5-10% of cases. Infiltrating ductal carcinoma accounts for most cases (70-90%) of male breast cancers. In situ but not invasive carcinoma is exclusively ductal and accounts for 7% of cases. Spread to lymph nodes is observed in 50-75% of cases. Immunohistochemical analysis shows that tumors are positive for progesterone and estrogen receptors more frequently in men than women. Diagnosis is based on clinical examination, ultrasonography, and mammography. Aspiration cytology often makes it possible to confirm the malignancy. Excisional biopsy with an immediate intraoperative pathology examination confirms malignancy and makes wider excision possible during the same procedure. A modified radical mastectomy with removal of some lymph nodes (Patey's mastectomy) is the standard basic treatment. Locoregional radiotherapy is very often indicated. Hormone therapy is also a first-line treatment. Chemotherapy is reserved for young men with substantial lymph node invasion and negative for hormonal receptors. The prognosis of breast cancer in men remains uncertain because of the frequently late diagnosis, unpredictable course, and high potential for metastasis.

Optimal treatment strategies in hormone-responsive early breast cancer: the role of aromatase inhibitors

Results from large controlled clinical trials have identified the third-generation aromatase inhibitors (AIs) as the first significant therapeutic advance in the adjuvant treatment of hormone receptor-positive (HR+) early breast cancer in postmenopausal women since the introduction of tamoxifen. Although all 3 agents, letrozole, exemestane and anastrozole, provide benefits compared with a 5-year course of tamoxifen, the optimum strategy for adjuvant AI therapy has not yet been defined. AIs have been studied upfront, in sequence with tamoxifen, in therapy switch strategies after 2-3 years of tamoxifen, and after the completion of standard adjuvant tamoxifen. Clearly, only upfront treatment with an AI can address the peak risk of relapse during the first 2-3 years after surgery, and both letrozole and anastrozole significantly reduce relapses compared with tamoxifen in this setting. Switching to exemestane or anastrozole benefits women who are disease-free following 2-3 years of tamoxifen, and women who have successfully completed the standard 5 years of tamoxifen can benefit from extended adjuvant letrozole therapy. Ongoing studies will help to determine the optimum treatment strategy, and answer other important questions, such as whether the AIs differ clinically, what influence HR expression profiles have on outcomes, and what long-term toxicities may be associated with these highly effective agents.