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Valproic acid as an adjunctive therapeutic agent for the treatment of breast cancer. Eur J Pharmacol 2018; 835:61-74. [DOI: 10.1016/j.ejphar.2018.07.057] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/27/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023]
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Layfield DM, Mohamud M, Odofin O, Walsh C, Royle GT, Cutress RI. Tumour grade on core biopsy and evidence of axillary involvement on ultrasound predicts response in elderly co-morbid patients treated with primary hormone therapy for oestrogen receptor positive breast carcinoma. Surgeon 2014; 13:61-8. [PMID: 24411703 DOI: 10.1016/j.surge.2013.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 11/01/2013] [Accepted: 11/21/2013] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Treatment of women with oestrogen-receptor positive breast cancer who are high risk for general anaesthetic remains controversial. Current guidance is based on studies pre-dating aromatase inhibitors (AIs) which may have also included hormone-receptor negative patients. Such studies have demonstrated improved disease-free survival and local disease control following surgery when compared with primary hormone therapy (PHT) alone. However uncertainty persists regarding benefit of surgery over optimal hormone treatment in patients with significant co-morbidity. METHOD Retrospective cohort study comparing efficacy of PHT in oestrogen-receptor positive breast cancer patients considered unsuitable for surgery. Co-morbidity was scored retrospectively using the Charlson Index. Overall survival and disease specific survival were noted and multivariate analysis performed to identify predictors of treatment failure. RESULTS 106 patients treated for breast cancer at Southampton University Hospital with PHT without surgery were identified (Mean age 84.1 years, range 48-101). 94.3% had a probability of 10 year survival of 2.25% or less according to the age-weighted Charlson score. Kaplan-Meier analysis demonstrated a four-year survival of 30% and breast cancer specific survival of 60%. Cox proportional hazards model demonstrated high-grade disease (grade III vs. grade I/II: HR = 2.007; 95% Confidence Interval (CI) = 1.004-4.014. P = 0.049) and ultrasound axillary staging (indeterminate/definite lymphatic involvement vs. no involvement: HR = 1.944; 95% CI = 1.010-3.742. P = 0.047) independently predicted early failure of PHT. CONCLUSION A high proportion of elderly and comorbid patients die with breast cancer rather than from breast cancer. Elderly comorbid patients who initially respond to primary hormone therapy have a less than 30% incidence of delayed treatment failure during their life time; however patients with grade III disease or an abnormal axillary ultrasound are twice as likely to fail first choice PHT.
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Affiliation(s)
- D M Layfield
- University of Southampton, UK; Southampton Breast Surgical Unit, University Hospitals Southampton, UK.
| | | | - O Odofin
- Southampton Breast Surgical Unit, University Hospitals Southampton, UK
| | - C Walsh
- Southampton Breast Surgical Unit, University Hospitals Southampton, UK
| | - G T Royle
- Southampton Breast Surgical Unit, University Hospitals Southampton, UK
| | - R I Cutress
- University of Southampton, UK; Southampton Breast Surgical Unit, University Hospitals Southampton, UK
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Beresford MJ, Ravichandran D, Makris A. Neoadjuvant endocrine therapy in breast cancer. Cancer Treat Rev 2007; 33:48-57. [PMID: 17134840 DOI: 10.1016/j.ctrv.2006.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Revised: 10/15/2006] [Accepted: 10/16/2006] [Indexed: 11/24/2022]
Abstract
The use of endocrine therapy is well established as a primary treatment for locally advanced breast cancer. However, despite the current popularity of neoadjuvant chemotherapy for operable tumours, there is relatively little published evidence for pre-operative endocrine therapy in operable disease, particularly outside of the elderly population. The wider use of aromatase inhibitors (AIs) has encouraged studies that compare the efficacy of AIs with tamoxifen in the neoadjuvant setting, but there remains a lack of comparison of neoadjuvant with adjuvant endocrine therapies. This review discusses the current evidence regarding primary endocrine therapy, along with the factors involved in choosing appropriate patients for neoadjuvant therapy and the current opinions on length of treatment time and measurement of response prior to surgery.
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Affiliation(s)
- M J Beresford
- Academic Oncology Unit, Mount Vernon Hospital, Mount Vernon Cancer Centre, Marie Curie Research Wing, Rickmansworth Road, Northwood, Middlesex, HA6 2RN, UK.
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Cataliotti L, Buzdar AU, Noguchi S, Bines J, Takatsuka Y, Petrakova K, Dube P, de Oliveira CT. Comparison of anastrozole versus tamoxifen as preoperative therapy in postmenopausal women with hormone receptor-positive breast cancer: the Pre-Operative "Arimidex" Compared to Tamoxifen (PROACT) trial. Cancer 2006; 106:2095-103. [PMID: 16598749 DOI: 10.1002/cncr.21872] [Citation(s) in RCA: 227] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The Pre-Operative "Arimidex" Compared to Tamoxifen (PROACT) study was a randomized, multicenter study comparing anastrozole with tamoxifen as a preoperative treatment of postmenopausal women with large, operable (T2/3, N0-2, M0), or potentially operable (T4b, N0-2, M0) breast cancer. The effect of preoperative endocrine therapy in patients scheduled for mastectomy or with inoperable tumors at baseline was also investigated. METHODS Patients with hormone receptor-positive breast cancer received anastrozole (n = 228) or tamoxifen (n = 223) with or without chemotherapy for 12 weeks before primary surgery. RESULTS Objective responses for anastrozole and tamoxifen occurred in 39.5% and 35.4% of patients, respectively (ultrasound measurements), and 50.0% and 46.2% of patients, respectively (caliper measurements). In hormonal therapy-only patients (n = 314), feasible surgery at baseline improved after 3 months in 43.0% of patients receiving anastrozole and 30.8% receiving tamoxifen (P = .04). In the intent-to-treat population, improvement in feasible surgery at baseline to actual surgery at 3 months was found to be numerically higher in the anastrozole group compared with the tamoxifen group, although this difference did not reach significance. Drug-related adverse events were reported in 20.2% and 18.1% of patients, respectively, in the anastrozole and tamoxifen groups. CONCLUSIONS Anastrozole is an effective and well-tolerated preoperative therapy, producing clinically beneficial tumor downstaging and reductions in tumor volume. These effects enable more minimal surgical interventions in patients scheduled for mastectomy, and mastectomy in patients with previously inoperable tumors. Anastrozole appears to be at least as effective as tamoxifen in this setting, and more effective than tamoxifen in certain clinically relevant subgroups. Cancer 2006. (c) 2006 American Cancer Society.
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Affiliation(s)
- Luigi Cataliotti
- Clinica Chirurgica 1, University degli Studi di Firenze, Firenze, Italy
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5
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Paepke S, Jacobs VR, Paepke D, Euler U, Blohmer JU, Warm M, Ohlinger R, Fischer T, Kiechle M, Harbeck N. Critical appraisal of primary systemic endocrine therapy in receptor-positive postmenopausal breast cancer: an update. Oncol Res Treat 2006; 29:210-7. [PMID: 16679783 DOI: 10.1159/000092267] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Even in elderly patients, greater consideration is now being given to tumor volume reduction in locally advanced breast cancer, with increased subsequent breast-conserving surgery. Neoadjuvant endocrine therapy offers the possibility of testing therapeutic efficacy in vivo, which is of great importance for optimal adjuvant treatment. Resulting therapy modifications can be expected to increase disease-free as well as overall survival. Recent results indicate that remission rates with primary chemotherapy are significantly lower in receptor-positive than in receptor-negative breast cancer and that efficacy parameters in receptor-positive tumors tend to favor primary endocrine therapy, highlighting the increased importance of this type of treatment. Aromatase inhibitors are superior to tamoxifen in terms of clinical response as well as breast conservation rate. Results from a small number of studies suggest that prolonged preoperative aromatase inhibitor therapy for up to 12 months can increase the rate of clinical and pathological complete remissions. In conclusion, primary endocrine therapy is a valid therapeutic option for postmenopausal patients with locally advanced hormone receptor-positive breast cancer and significant comorbidity, increased risk of complications with regard to anesthesia and surgery, desire for breast-conserving surgery and/or reduced suitability for chemotherapy, as well as in very old patients.
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Affiliation(s)
- Stefan Paepke
- Frauenklinik des Universitätsklinikums rechts der Isar, Technische Universität München, Germany.
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6
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Huober J, Krainick-Strobel U, Kurek R, Wallwiener D. Neoadjuvant Endocrine Therapy in Primary Breast Cancer. Clin Breast Cancer 2004; 5:341-7. [PMID: 15585070 DOI: 10.3816/cbc.2004.n.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neoadjuvant chemotherapy has been employed increasingly in operable breast cancer during recent years. Several randomized trials showed that the chances of breast conserving therapy are being enhanced, and that survival was not compromised by primary systemic therapy compared to adjuvant treatment. Apart from the surgical advantages of tumor downstaging and breast conservation, therapy upfront might offer the chance to predict subsequent response of an individual patient to a given agent in the adjuvant setting. Furthermore, by investigating pre- and posttreatment tumor specimens, the neaodjuvant setting might help to evaluate new predictive biological markers, assess biologic effects of new treatments, and gain insight into molecular mechanisms. For postmenopausal patients with receptor-positive disease who cannot tolerate the toxicities of chemotherapy regimens or are not eligible for immediate surgery, endocrine treatment is emerging as an attractive alternative in the neoadjuvant setting. The new third-generation aromatase inhibitors letrozole and anastrozole have been compared to tamoxifen in 3 well-designed randomized neoadjuvant phase III trials (PO24, IMPACT, and PROACT). These studies showed significantly higher response rates for letrozole than for tamoxifen, and comparable ones for anastrozole. Thus, the primary use of an aromatase inhibitor seems a feasible and safe treatment option for postmenopausal women with early-stage breast cancer who do not wish to or are unable to undergo immediate surgery or preoperative chemotherapy. Further neoadjuvant endocrine trials should help us to elucidate the cross-talk between the different signal transduction pathways and their role in endocrine resistance.
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Affiliation(s)
- Jens Huober
- Department of Gynecology and Obstetrics, University of Tuebingen, Germany.
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7
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Freedman OC, Verma S, Clemons MJ. Using aromatase inhibitors in the neoadjuvant setting: evolution or revolution? Cancer Treat Rev 2004; 31:1-17. [PMID: 15707700 DOI: 10.1016/j.ctrv.2004.09.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite improvements in the management of patients with early breast cancer, the prognosis for women with locally advanced breast cancer (LABC) remains poor. The potential goals of neoadjuvant treatment for this disease include down-sizing tumours to allow breast conservation as well as the possibility of improving survival rates. Neoadjuvant treatment was initially dominated by chemotherapy, which increased rates of breast conserving surgery, but to date has demonstrated no survival benefit over standard adjuvant chemotherapy. With recent advances in endocrine therapy, and rapid and routine assessment of predictive factors of response such as estrogen (ER), progesterone (PR) and Her2 nu receptor status, endocrine therapy has come to the forefront of research investigating a neoadjuvant alternative to chemotherapy. Early studies of neoadjuvant endocrine therapy mainly evaluated the role of tamoxifen in the treatment of elderly postmenopausal women with LABC who were unselected for ER/PR status and were unsuitable for either surgery or chemotherapy. Response rates in these patients were found to be inferior to those traditionally obtained from trials with neoadjuvant chemotherapy. Paralleling the superiority that third-generation aromatase inhibitors have shown over tamoxifen in the metastatic and adjuvant settings however, AIs have also demonstrated superiority in the neoadjuvant setting. Recent studies have shown response rates for neoadjuvant treatment with aromatase inhibitors in carefully selected hormone receptor positive patients to be comparable to those seen with neoadjuvant chemotherapy. This is particularly important as hormone receptor positive tumours have repeatedly been shown to have lower response rates to neoadjuvant chemotherapy than hormone receptor negative tumours. Neoadjuvant endocrine treatment with aromatase inhibitors has therefore evolved from being an experimental effort to palliate women with LABC unsuitable for surgery or chemotherapy, to representing a viable and possibly preferred alternative for postmenopausal women with hormone receptor positive large tumours or LABC. Further benefits of neoadjuvant trials include allowing the study of predictive biomarkers of disease in order to provide insight into therapy resistance and sensitivity, and identifying promising systemic therapies for additional testing in larger adjuvant trials.
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Affiliation(s)
- O C Freedman
- Division of Medical Oncology, Toronto-Sunnybrook Regional Cancer Centre, 2075 Bayview Avenue, Toronto, Ont., Canada M4N 3M5
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8
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Margueron R, Duong V, Castet A, Cavaillès V. Histone deacetylase inhibition and estrogen signalling in human breast cancer cells. Biochem Pharmacol 2004; 68:1239-46. [PMID: 15313422 DOI: 10.1016/j.bcp.2004.04.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2004] [Accepted: 04/19/2004] [Indexed: 11/30/2022]
Abstract
Estrogens are steroid hormones, which act through specific nuclear estrogen receptors (ERalpha and ERbeta) and are important regulators of breast cancer growth. These receptors control gene expression by recruiting transcriptional cofactors that exhibit various enzymatic activities such as histone acetyltransferase or histone deacetylase (HDAC) which target histone as well as non-histone substrates. The ERalpha itself and some of the transcriptional regulators have been shown to be acetylated proteins. Research performed over the last decade has highlighted the role of HDAC inhibitors (HDACi) as modulators of transcriptional activity and as a new class of therapeutic agents. In human cancer cells, inhibition of HDACs controls the expression of the ERalpha gene and the transcriptional activity in response to partial antiestrogens such as 4-hydroxytamoxifen. Various HDACi strongly inhibit breast cancer cell proliferation and ERalpha-negative (ER-) appear less sensitive than ERalpha-positive (ER+) cell lines. p21WAF1/CIP1 gene expression, in relation with ERalpha levels, could play a role in this differential response of breast cancer cells to hyperacetylating agents.
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Affiliation(s)
- Raphaël Margueron
- INSERM U540 Endocrinologie Moléculaire et Cellulaire des Cancers and Université de Montpellier I, 60 Rue de Navacelles, 34090, France
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9
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Schwartz GF, Hortobagyi GN. Proceedings of the Consensus Conference on Neoadjuvant Chemotherapy in Carcinoma of the Breast, April 26-28, 2003, Philadelphia, Pennsylvania. Breast J 2004. [DOI: 10.1111/j.1075-122x.2004.21594.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Schwartz GF, Hortobagyi GN. Proceedings of the consensus conference on neoadjuvant chemotherapy in carcinoma of the breast, April 26-28, 2003, Philadelphia, Pennsylvania. Cancer 2004; 100:2512-32. [PMID: 15197792 DOI: 10.1002/cncr.20298] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Gordon F Schwartz
- Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania 19107, USA.
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Hawkin RA, Arends MJ, Ritchie AA, Langdon S, Miller WR. Tamoxifen increases apoptosis but does not influence markers of proliferation in an MCF-7 xenograft model of breast cancer. Breast 2004; 9:96-106. [PMID: 14731708 DOI: 10.1054/brst.2000.0140] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Twenty-four nude mice bearing MCF-7 breast cancer cells grown as xenografts and treated with tamoxifen (2.5 mg slow-release pellet) were studied for up to 35 days. Tumour size was measured in 2 dimensions at regular time-intervals and tumours were harvested on each of days 2, 4, 7, 14, 28 and 35 after the start of treatment. Control animals (8) received no treatment and the tumours were harvested after 0 or 35 days. Tumour sections were assessed for prevalence of apoptosis and mitosis and examined immunocytochemically for Ki(67)(MIB-1) and bcl-2 expression. Tumours increased in size during tamoxifen-treatment, but at a significantly slower rate (max. 2.6-fold) than in the untreated control animals; thus tumours not actually regressing may, nevertheless, be responding significantly to tamoxifen. MIB-1 and bcl-2 immunostaining and mitosis failed to show any consistent change over the period of study. Apoptosis, however, increased progressively and significantly to day-28 in tamoxifen-treated tumours, reaching approximately a 5-fold increase over day-0 values, then decreasing again to nearly 3-fold by day-35 (P= 0.0002). The apoptosis: mitosis ratio in treated tumours also increased to approximately 10-fold on day-28 over day-0 values, decreasing to nearly 4-fold by day-35 (P= 0.037). Within the treated group, apoptosis was significantly inversely correlated with both mitosis (R = -0.38, P= 0.03) and expression of bcl-2 (R = -0.48, P= 0.0056) and strongly positively correlated with both time on tamoxifen (R = +0.63, P= 0.0003) and the % inhibition of growth by tamoxifen (R = +0.58,P = 0.0012) in the 28 individual, treated tumours (estimated relative to the mean growth rate in the controls). The apoptosis: mitosis ratio was also inversely correlated with bcl-2 expression (R = -0.56, P= 0.0021) and positively correlated with both time on tamoxifen (R = +0.50, P= 0.0068) and % inhibition of growth (R = +0.56, P= 0.0019). In this hormone-sensitive tumour model for breast cancer, in which tamoxifen caused inhibition rather than regression, it was not possible to detect significant changes in the marker proteins Ki(67)and bcl-2, or in the prevalence of mitosis in relation to treatment; these factors may therefore not be accurate indices of response to tamoxifen in all situations. By contrast, however, tamoxifen induced a significant, early increase in the prevalence of apoptosis associated with inhibition of tumour growth and an inverse relationship in both mitosis and bcl-2 expression, suggesting that apoptosis may be an accurate and sensitive early marker of even a moderate response to tamoxifen.
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Affiliation(s)
- R A Hawkin
- Edinburgh Breast Unit Research Group, The Medical School, Teviot Place, Edinburgh EH8 9AG, UK
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12
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Affiliation(s)
- A Goldhirsch
- Department of Medicine, European Institute of Oncology, Milan, Italy
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13
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Abstract
The role of neoadjuvant chemotherapy in locally advanced breast cancer is firmly established. There is now also an emerging role for neoadjuvant systemic therapy in the treatment of operable breast cancer. There is good evidence that the chances of breast conserving surgery can be increased with this approach and results of randomised studies indicate that survival is at least as good with neoadjuvant as with adjuvant chemotherapy. Similar clinical data are emerging with neoadjuvant endocrine therapy. For the future, there are important potential advantages in having an in vivo measure of chemosensitivity rather than blindly treating micrometastatic disease in the adjuvant setting. Clinical response to neoadjuvant treatment, and in particular complete pathological response, are predictors of subsequent outcome. Pathological involvement of axillary nodes following neoadjuvant therapy portends a poor prognosis. The potential for biological surrogate markers of response to predict for long-term outcome may allow individualisation of systemic treatment and the rapid assessment of new drugs in early breast cancer.
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Affiliation(s)
- Catherine Shannon
- Breast Unit, Royal Marsden NHS Trust, Fulham Road, London SW3 6JJ, UK
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Hislop RG, Pratt N, Stocks SC, Steel CM, Sales M, Goudie D, Robertson A, Thompson AM. Karyotypic aberrations of chromosomes 16 and 17 are related to survival in patients with breast cancer. Br J Surg 2002; 89:1581-6. [PMID: 12445070 DOI: 10.1046/j.1365-2168.2002.02270.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Breast cancer has a high incidence and associated mortality rate, yet little is known of the sequence of genetic events that underlie the clinical course. METHODS The study was a comparative genomic hybridization analysis of 40 primary breast cancers with survival data at a mean of 8.4 years. RESULTS The mean number of aberrations was 9.0, with a mean of 5.5 gains and 3.5 deletions per tumour. The most common aberrations were: gain of 1q (27 of 40), 8q (19 of 40) and 17q (13 of 40), and deletion of 17p (12 of 40) and 8p (11 of 40). These results are consistent with a distinctive pattern of large-scale (karyotypic) genetic change in primary breast cancer. CONCLUSION The novel findings of this study were that only women who were disease-free had loss of 16q (E-cadherin) in association with a gain of 16p, and 17p13 (p53) loss combined with 17q12 (HER2) amplification was found only in the cancers of women who developed recurrent disease. The karyotypic changes seen in primary breast cancer seem to be associated with outcome and point to the underlying genetic events.
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Affiliation(s)
- R G Hislop
- Departments of Molecular and Cellular Pathology, University of Dundee, Tayside University Hospitals Trust, Dundee, UK
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15
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Anderson TJ, Dixon JM, Stuart M, Sahmoud T, Miller WR. Effect of neoadjuvant treatment with anastrozole on tumour histology in postmenopausal women with large operable breast cancer. Br J Cancer 2002; 87:334-8. [PMID: 12177804 PMCID: PMC2364231 DOI: 10.1038/sj.bjc.6600435] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2001] [Revised: 04/22/2002] [Accepted: 05/08/2002] [Indexed: 11/28/2022] Open
Abstract
Anastrozole is an orally active, non-steroidal aromatase inhibitor which appears effective as neoadjuvant treatment of breast cancer. Histological changes have been evaluated in biopsies from large, oestrogen-receptor rich, operable breast tumours in postmenopausal women following 12 weeks of neoadjuvant anastrozole treatment (1 mg (n=12) or 10 mg (n=11)). Of the 23 patients, 18 had a clinical response following treatment. Compared with pre-treatment biopsies anastrozole-treated specimens displayed decreased cellularity and/or increased fibrosis in 15 tumours; changes in gland formation, nuclear pleomorphism, or mitoses, in 12 cases; and a reduction in Mib1 score in all tumours. Marked changes in apoptotic scores were seen following treatment but the direction of effect was inconsistent. In all 17 tumours which were positive for progesterone receptors before therapy, treatment was associated with reduced staining for progesterone receptors. There was no consistent effect of treatment on oestrogen-receptor expression. It is concluded that neoadjuvant anastrozole treatment in this patient group has marked effects on tumour histopathology but these do not always correlate with clinical response.
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Affiliation(s)
- T J Anderson
- Department of Pathology, Western General Hospital, Edinburgh EH4 2XU, UK
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Boeddinghaus I, Dowsett M. Recent Developments in the Hormonal Treatment of Breast Cancer. Breast Cancer 2002. [DOI: 10.1201/b14039-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Hawkins RA, Tesdale AL, Prescott RJ, Forster T, McIntyre MA, Baker P, Jack WJL, Chetty U, Dixon JM, Killen ME, Hulme MJ, Miller WR. Outcome after extended follow-up in a prospective study of operable breast cancer: key factors and a prognostic index. Br J Cancer 2002; 87:8-14. [PMID: 12085248 PMCID: PMC2364292 DOI: 10.1038/sj.bjc.6600335] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2001] [Revised: 03/19/2002] [Accepted: 04/08/2002] [Indexed: 11/09/2022] Open
Abstract
In 1990, 215 patients with operable breast cancer were entered into a prospective study of the prognostic significance of five biochemical markers and 15 other factors (pathological/chronological/patient). After a median follow-up of 6.6 years, there were 77 recurrences and 77 deaths (59 breast cancer-related). By univariate analysis, patient outcome related significantly to 13 factors. By multivariate analysis, the most important of nine independent factors were: number of nodes involved, steroid receptors (for oestrogen or progestogen), age, clinical or pathological tumour size and grade. Receptors and grade exerted their influence only in the first 3 years. Progestogen receptors (immunohistochemical) and oestrogen receptors (biochemical) were of similar prognostic significance. The two receptors were correlated (r=+0.50, P=0.001) and displaced each other from the analytical model but some evidence for the additivity of their prognostic values was seen when their levels were discordant.
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Affiliation(s)
- R A Hawkins
- University Department of Surgery, Royal Infirmary NHS Trust, Edinburgh EH3 9YW, UK.
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18
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Tan SM, Cheung KL, Willsher PC, Blamey RW, Chan SY, Robertson JF. Locally advanced primary breast cancer: medium-term results of a randomised trial of multimodal therapy versus initial hormone therapy. Eur J Cancer 2001; 37:2331-8. [PMID: 11720825 DOI: 10.1016/s0959-8049(01)00298-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We report the medium-term (median follow-up=52 months) results of a prospective randomised trial of multimodal therapy (neoadjuvant chemotherapy, Patey mastectomy, postoperative radiotherapy and adjuvant hormone therapy) (n=56) versus initial hormone therapy (n=52) for locally advanced primary breast cancer. Compared with multimodal therapy, initial hormone therapy was associated with reduced number of therapies for disease control (mean=3.6 versus 4.9) and mastectomy rate (31%). Multimodal therapy conferred better initial locoregional control and a longer disease-free interval. Nevertheless, there was no statistically significant differences in the rates of survival, metastasis and uncontrolled locoregional disease, as well as in the time to metastasis between the two therapy groups. Regardless of the therapy groups, oestrogen receptor positivity conferred a lower metastasis rate, better survival and locoregional control. Thus, initial hormone therapy may be a reasonable option for managing locally advanced primary breast cancer, especially for oestrogen receptor-positive tumours.
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Affiliation(s)
- S M Tan
- Department of Surgery, City Hospital, Nottingham, UK
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Dixon JM, Love CD, Bellamy CO, Cameron DA, Leonard RC, Smith H, Miller WR. Letrozole as primary medical therapy for locally advanced and large operable breast cancer. Breast Cancer Res Treat 2001; 66:191-9. [PMID: 11510690 DOI: 10.1023/a:1010669403283] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS To investigate the efficacy of letrozole 2.5 mg and 10 mg used as primary neoadjuvant therapy for patients with locally advanced and large operable breast cancer. PATIENTS AND METHODS Twenty-four postmenopausal patients with locally advanced or large operable breast cancer were treated in two consecutive series with letrozole 2.5 mg (n = 12) or letrozole 10 mg (n = 12). Response at three months was measured by change in tumor volume according to WHO criteria (partial response was defined as a reduction in tumor volume > or = 65%). Tumor volumes were assessed clinically, by ultrasound and mammography, and pathologically. RESULTS All 24 patients were estrogen receptor-positive, were considered 'receptor-rich', and mean age was 77.6 years and 71.6 years in the letrozole 2.5 mg and 10 mg treatment groups, respectively. There were five complete clinical responses and seven partial clinical responses in the patients treated with 2.5 mg letrozole, and nine partial responses and three patients with stable disease in patients treated with 10 mg letrozole. Assessed by ultrasound and mammography, the 12 patients treated with 2.5 mg had one complete response, nine partial responses and two with no change. In the 12 patients treated with 10 mg letrozole, imaging gave eight partial responses and four with no change. One patient treated with the 2.5 mg dose had a complete clinical and pathological response. There was no significant difference between the two doses in effect on tumor volume, and no recordable side effects associated with either dose. CONCLUSION Letrozole used in a neoadjuvant setting is highly effective, producing clinically beneficial reductions in tumor volume allowing all patients to have breast conserving surgery, and has an acceptable safety profile.
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Affiliation(s)
- J M Dixon
- Edinburgh Breast Unit, Western General Hospital.
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Abstract
Preoperative hormone therapy for breast cancer has the potential to downstage a primary tumour hence increasing operability as well as making breast conservation feasible. Whether it will achieve any clinically significant survival benefit remains to be elucidated. Preoperative hormone therapy, in contrast to neoadjuvant chemotherapy, produces less severe side effects and can be continued throughout the perioperative period. Presurgical studies have demonstrated anti-tumour effects of hormone therapy, e.g. down-regulation of ER. Current clinical trials have shown that, in patients with ER positive tumours, a response approaching 70% is reached in approximately three months using the traditional hormonal agent tamoxifen. The tumour seldom progresses during this period. New agents (such as third generation aromatase inhibitors and pure anti-oestrogens) may produce more profound and rapid responses. Future trials are required to identify factors other than ER to precisely predict response so that appropriate patients can be selected. The best agents, the ideal methods of monitoring response and the optimum duration of therapy also need to be identified. Clinical trials also need to test if pre- and perioperative hormone therapy is superior to conventional adjuvant hormone therapy in patients with early breast cancer.
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Affiliation(s)
- K L Cheung
- Professorial Unit of Surgery, City Hospital, Nottingham, UK
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21
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Ellis MJ. Preoperative endocrine therapy for older women with breast cancer: renewed interest in an old idea. Cancer Control 2000; 7:557-62. [PMID: 11088064 DOI: 10.1177/107327480000700607] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Tamoxifen as sole therapy (primary tamoxifen therapy) was investigated in the 1970s and 1980s as an alternative to surgery for older patients with breast cancer. While the majority of primary breast tumors responded to tamoxifen, long-term local disease control was poor. The use of primary tamoxifen therapy is therefore restricted to frail, elderly, and infirm patients who cannot tolerate surgery. In contrast, short-term preoperative endocrine therapy to downstage estrogen receptor-positive (ER+) tumors is under increasing scrutiny as a nontoxic neoadjuvant approach for older women. METHODS The literature on primary tamoxifen therapy and preoperative endocrine therapy was reviewed to construct an opinion piece on the feasibility and safety of preoperative endocrine therapy. RESULTS A review of nine phase II trials and a meta-analysis of two randomized trials suggest that the initial response rates to preoperative endocrine therapy will exceed 50% to 60% for patients with ER+ disease. A short delay in surgery to administer 3 to 4 months of preoperative endocrine therapy is unlikely to compromise long-term outcomes. CONCLUSIONS Preoperative endocrine therapy is a logical approach for older patients with ER+ disease as a well-tolerated means to increase the rate of breast-conserving surgery. Several clinical trials comparing tamoxifen with selective aromatase inhibitors in the preoperative setting have been conducted, and the results are expected soon. These studies will determine if a large multicenter national trial of preoperative endocrine therapy should be conducted.
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Affiliation(s)
- M J Ellis
- Duke University Clinical Breast Cancer Program, Duke University Medical Center, Durham, NC 27710, USA
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22
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Abstract
Chemotherapy and tamoxifen will continue to play an important role in the treatment of patients with primary breast cancer. Future clinical trials will clarify the role of HDCT for patients at high risk. Molecular markers of response may assist in drug selection in the adjuvant setting. Development of novel therapeutic agents continues based on an expanded biologic understanding of tumor development and progression.
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Affiliation(s)
- F J Esteva
- Department of Breast Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, USA.
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23
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Makris A, Powles TJ, Allred DC, Ashley SE, Trott PA, Ormerod MG, Titley JC, Dowsett M. Quantitative changes in cytological molecular markers during primary medical treatment of breast cancer: a pilot study. Breast Cancer Res Treat 1999; 53:51-9. [PMID: 10206072 DOI: 10.1023/a:1006179511178] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIM To quantify the changes in biological molecular markers during primary medical treatment in patients with operable breast cancer and to assess their possible relationship with response to treatment. METHODS The treatment group consisted of 31 patients with operable breast carcinomas, median age 57 years (range 41-67), treated with four 3-weekly cycles of chemotherapy with Mitoxantrone, methotrexate (+/- mitomycin C), and tamoxifen before surgery. Fine needle aspiration (FNA) was used to obtain samples from patients prior to and at 10 or 21 days post-treatment. The following molecular markers were assessed: estrogen receptor (ER), progesterone receptor (PgR), p53, Bcl-2, and Ki67 measured by immunocytochemistry, and ploidy and S-phase fraction (SPF) by flow cytometry. To evaluate the reproducibility of the technique, repeat FNA was performed in a separate non-treatment control group of 20 patients and the same molecular markers assessed, two weeks after the first sample with no intervening treatment. RESULTS The non-treatment control group showed a high reproducibility for the measurement of molecular markers from repeat FNA. In the treatment group there was a non-significant reduction in SPF and a significant reduction (p = 0.005) in Ki67. Patients who responded to neoadjuvant therapy were more likely to have a reduction in these two markers than those who failed to respond. Similarly, a reduction in ER scores was observed between the first and second samples (p = 0.04). For PgR, the change between the first and second samples was not significant although there was a significant difference between responders and non-responders (p = 0.03). All nine patients with an increase in PgR were responders. No significant changes in p53 or Bcl-2 were observed during treatment. CONCLUSION Molecular markers can be adequately measured from FNA samples prior to and during neoadjuvant therapy. Changes in cellular proliferation and hormone receptors have been shown that may be related to tumour response. These relationships should be assessed in a larger cohort of patients.
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Affiliation(s)
- A Makris
- Royal Marsden Hospital, Sutton, Surrey, UK
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24
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Absence of mutations in sites of key functional importance of the RIα and RIIβ regulatory subunits of protein kinase A in human breast cancers. Breast 1998. [DOI: 10.1016/s0960-9776(98)90024-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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25
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Thompson AM, Elton RA, Hawkins RA, Chetty U, Steel CM. PS2 mRNA expression adds prognostic information to node status for 6-year survival in breast cancer. Br J Cancer 1998; 77:492-6. [PMID: 9472649 PMCID: PMC2151284 DOI: 10.1038/bjc.1998.78] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Expression of pS2, an oestrogen-regulated gene, has been associated with a good short-term prognosis and response to endocrine therapy. The aim of this study was to determine whether expression of mRNA for the pS2 gene in breast cancer could contribute useful information on disease behaviour and survival at medium-term follow-up. Northern blotting was used to detect pS2 messenger ribonucleic acid (mRNA) in the primary tumour tissue from each of 90 patients with breast cancer. Axillary node status was established by sampling or clearance, oestrogen receptor concentration by enzyme immunosorbant assay and follow-up was continued for at least 6 years or until death. At 83 months mean follow-up, 29 of 90 (32%) patients had recurrent disease and, of these, 18 (20%) had died from breast cancer. pS2 mRNA expression, present in 26 of 90 (29%) cancers, was associated with freedom from disease recurrence (P = 0.026) and was significantly associated with survival at a minimum of 6 years follow-up (P < 0.001). Pathological node status and tumour size were also significantly associated with disease recurrence (P < 0.001 and P = 0.002 respectively) and inversely with survival (P < 0.001 and P < 0.001 respectively). After multiple Cox regression analysis, pS2 expression was still a significant predictor of recurrence (but not survival) after adjusting for node status and tumour size; oestrogen receptor was an independent predictor of survival. The combination of node status and pS2 expression discriminated patients with particularly good prognosis (node negative, pS2 positive: no mortality at 6 years) or poor prognosis (node positive, pS2 negative; 41% mortality at 6 years). Evaluation of pS2 expression in breast cancer at diagnosis may provide additional useful prognostic information to conventional staging.
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Affiliation(s)
- A M Thompson
- Department of Surgery, Ninewells Hospital and Medical School, Dundee, UK
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26
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Kwon A, Yamada O, Uetsuji S, Matsui Y, Kamiyama Y. Surg Laparosc Endosc Percutan Tech 1997; 7:223-227. [DOI: 10.1097/00019509-199706000-00009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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27
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Makris A, Allred DC, Powles TJ, Dowsett M, Fernando IN, Trott PA, Ashley SE, Ormerod MG, Titley JC, Osborne CK. Cytological evaluation of biological prognostic markers from primary breast carcinomas. Breast Cancer Res Treat 1997; 44:65-74. [PMID: 9164679 DOI: 10.1023/a:1005717924761] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This study was undertaken to evaluate our ability to detect multiple molecular markers of prognosis and response to treatment in fine needle aspirates (FNA) from patients with primary breast carcinomas. 147 patients with operable primary breast carcinomas who had been recruited to a randomized trial of primary medical therapy (PMT) versus adjuvant chemoendocrine therapy were analysed. FNAs were taken prior to therapy and from this multiple slides were produced using cytospin cytocentrifugation and stored at -80 degrees C for subsequent immunocytochemical analysis (ICA). ICA was performed for oestrogen receptor (ER), progesterone receptor (PgR), p53, Ki67, and Bcl-2. Part of the aspirate was snap frozen and used for flow cytometric analysis of ploidy and S-phase fraction (SPF). In a subgroup of 50 patients who had surgery prior to systemic therapy, as well as FNAs, sections were also taken from paraffin-embedded blocks and stained by ICA for ER, PgR and p53 for validation. In these patients ER was additionally measured by enzyme immunoassay (EIA) from frozen tissue taken at surgery. ER, PgR, p53, Bcl-2, and Ki67 were successfully detected by ICA while ploidy and SPF were successfully measured by flow cytometry from FNA material. The percentage positive values obtained were reasonable and as follows: 74% for ER, 70% for PgR, 36% for p53, 80% for Bcl-2,68% of tumours were aneuploid and 32% diploid. Significant relationships between these measurements were observed in accordance with expectations. The concordance for ER, PgR, and p53 from FNA when compared to ICA of matching histological sections was 91.5%, 75.5%, and 75% respectively. For ER the concordance between measurement by ICA of cytological and histological samples and by EIA of frozen tissue was 82.5% and 84% respectively. These results indicate that multiple molecular markers can be adequately tested on cytological preparations from primary breast tumours. These markers can be used to determine prognosis and predict response to PMT.
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Affiliation(s)
- A Makris
- Royal Marsden Hospital, Sutton, Surrey, UK
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28
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Benson JR, Colletta AA. Changes in expression of transforming growth factor beta mRNA isoforms in patients undergoing tamoxifen therapy. Br J Cancer 1997; 75:776-8. [PMID: 9043041 PMCID: PMC2063342 DOI: 10.1038/bjc.1997.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
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29
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Willsher PC, Robertson JF, Chan SY, Jackson L, Blamey RW. Locally advanced breast cancer: early results of a randomised trial of multimodal therapy versus initial hormone therapy. Eur J Cancer 1997; 33:45-9. [PMID: 9071898 DOI: 10.1016/s0959-8049(96)00367-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The aim of this study was to investigate initial treatment of locally advanced breast cancer. Patients were randomised to "multimodal" therapy (pre-operative chemotherapy, Patey mastectomy, flap irradiation and adjuvant hormone therapy) (n = 55), or initial "hormone" therapy (n = 53) with further therapy upon tumour progression. The objective response to chemotherapy was 57% (31/54) after four cycles. Of patients on hormone therapy, 36% (19/53) had an objective response and 32% (17/53) disease stasis at a 6 month assessment. At a median 30 months follow-up, there was no notable difference in development of metastases or survival: only 6 patients have uncontrolled loco-regional relapse (4 "hormonal", 2 "multimodal"). The number of treatments per patient required for this loco-regional control was lower in the "hormone" group (mean 2.13 versus 4.20 in the "multimodal" group). This small study has shown that the use of consecutive therapies, with the aim of tumour control, does not appear to compromise outcome in comparison with initial "multi-modal" therapy. Adopting such a policy may allow some patients to avoid unnecessary treatments.
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Affiliation(s)
- P C Willsher
- Department of Surgery, City Hospital, Nottingham, U.K
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30
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Cameron DA, Anderson ED, Levack P, Hawkins RA, Anderson TJ, Leonard RC, Forrest AP, Chetty U. Primary systemic therapy for operable breast cancer--10-year survival data after chemotherapy and hormone therapy. Br J Cancer 1997; 76:1099-105. [PMID: 9376273 PMCID: PMC2228097 DOI: 10.1038/bjc.1997.514] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Between 1984 and 1990, 94 women presenting to the Edinburgh Breast Unit with operable breast cancer of 4 cm or greater in diameter (T2, T3, N0, N1, M0) were given preoperative systemic therapy. Initially, all women received hormone therapy, with CHOP (cyclophosphamide 1 g m(-2), doxorubicin 50 mg m(-2), vincristine 1.4 mg m(-2) to a maximum of 2 mg and prednisolone 40 mg per day orally for 5 days) chemotherapy being administered to those who failed to respond by 3 months. After April 1987, first-line hormone therapy was only offered to women with oestrogen receptor (ER)-moderate/-rich (> 20 fmol mg(-1) protein) tumours, and CHOP was reserved for those women whose tumours failed to respond to hormone therapy and for those with ER-negative/-poor tumours. Response data have been published previously (Anderson et al, 1991). After a median follow-up of 7.5 years, there is no difference in survival between those women given initial hormone therapy and those given chemotherapy, with neither group having yet reached its median survival. The two key factors that predicted for a poor survival were the number of involved axillary nodes after preoperative systemic therapy (P < 0.00001) and a lack of response to preoperative therapy (P < 0.05). These data suggest that many women with ER-moderate/-rich tumours will have a good prognosis after preoperative hormone therapy alone. However, it is possible to identify, by their post-systemic therapy axillary node status, a group of women who still have an appalling prognosis after preoperative chemotherapy or hormone therapy.
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Affiliation(s)
- D A Cameron
- ICRF Medical Oncology Unit, Western General Hospital, Edinburgh, UK
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31
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Cameron D, Leonard R. Primary medical therapy for operable breast cancer. Breast 1996. [DOI: 10.1016/s0960-9776(96)90000-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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32
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MacCallum J, Keen JC, Bartlett JM, Thompson AM, Dixon JM, Miller WR. Changes in expression of transforming growth factor beta mRNA isoforms in patients undergoing tamoxifen therapy. Br J Cancer 1996; 74:474-8. [PMID: 8695368 PMCID: PMC2074656 DOI: 10.1038/bjc.1996.385] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Tumour was obtained from 37 patients with oestrogen receptor-positive breast cancer, before and during treatment with tamoxifen, and examined qualitatively and semi-qualitatively for mRNA of the three mammalian TGF-beta isoforms. Levels of TGF-beta isoforms were then correlated with tumour response to tamoxifen, as assessed by monthly ultrasound. A high incidence of expression by each isoform was found in tumour material taken both before and during treatment. Semiquantitative assessment of mRNA showed that in the majority of tumours, expression of TGF-beta s did not change markedly with treatment, i.e. beyond that which might have been caused by method reproducibility and tumour heterogeneity (variations of < 100% between pre- and post-treatment samples). In those displaying significant variation with treatment, expression of TGF-beta 1 and -beta 3 increased or decreased in equal numbers, whereas TGF-beta 2 expression tended to increase with treatment. Subdividing tumours by clinical response revealed no significant association between changes in expression of TGF-beta 1 and TGF-beta 3. There was, however, a significant correlation between changes in expression of TGF-beta 2 and response (P = 0.018). Thus, of 15 responding tumours displaying substantial changes, 11 showed an increase in TGF-beta 2 expression with treatment, whereas none of the non-responding tumours were associated with increased expression. While not providing evidence for a generalised increase in TGF-beta expression with tamoxifen treatment, the present study suggests that response to tamoxifen therapy may be associated with an increase in expression of specific TGF-beta isoforms in some, but not all, tumours.
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Affiliation(s)
- J MacCallum
- University Department of Surgery, Edinburgh Royal Infirmary, UK
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33
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Willsher PC, Robertson JF, Armitage NC, Morgan DA, Nicholson RI, Blamey RW. Locally advanced breast cancer: long-term results of a randomized trial comparing primary treatment with tamoxifen or radiotherapy in post-menopausal women. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1996; 22:34-7. [PMID: 8846863 DOI: 10.1016/s0748-7983(96)91352-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
We have previously reported the early results of a randomized cross-over study of radical radiotherapy vs tamoxifen in patients with locally advanced breast cancer. This study has now recruited 143 patients with a median time from randomization of almost 10 years for both groups. Seventy-three patients received 20 mg tamoxifen twice daily, and 70 had primary radiotherapy at a dose of 40 Gy, which is a lower dose than currently administered. The treatment groups were similar in age, size of tumour and oestrogen receptor status. There was no significant difference between the two treatment groups for the combined initial response and static disease rates (89% for radiotherapy and 78% for tamoxifen, P = 0.15). The median duration of initial response was 12 months for both groups. When patients crossed over to the alternative therapy on local relapse, there was no difference in response/static disease rates (P = 0.34) and duration of response (P = 0.76). A non-significant prolongation of the metastatic-free interval in favour of tamoxifen (P = 0.08) was identified, although there was no difference in survival outcome (P = 0.38). This study shows that in this group of patients primary tamoxifen offers a similar clinical benefit to primary radiotherapy at a dose of 40 Gy, and is therefore an acceptable alternative primary treatment.
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Affiliation(s)
- P C Willsher
- Department of Surgical Science, City Hospital, Nottingham, UK
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34
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Abstract
Oestrogen receptor (ER) expression in breast cancer is regarded as a phenotype that may change during the natural history of the disease or during endocrine therapy. It has been suggested that in up to 70% of tumours that show acquired resistance the mechanism may be changed in ER status from positive to negative. This paper proposes an alternative hypothesis that ER expression in a stable phenotype in breast cancer. The paper reviews the literature on ER expression during the natural history of breast cancer in patients and also presents data on the effect of endocrine therapy on ER expression. If the alternative hypothesis is true it has important implications for treatment from chemoprevention to acquired endocrine resistance in advanced disease. Equally, if the hypothesis is true, attempts to develop laboratory models of endocrine resistance where ER-positive tumours become ER negative need to be re-evaluated.
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35
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Hortobagyi GN, Buzdar AU, Strom EA, Ames FC, Singletary SE. Primary chemotherapy for early and advanced breast cancer. Cancer Lett 1995; 90:103-9. [PMID: 7720036 DOI: 10.1016/0304-3835(94)03684-b] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
While locally advanced breast cancer (LABC) represents a small fraction of patients with breast cancer in industrialized nations, in developing countries it might constitute up to 50% of incident cases. The definition includes patients with stage IIB, III, and some with limited stage IV breast cancer. Inflammatory breast cancer (IBC) is part of LABC, but it is often reported separately, because of its dismal prognosis. LABC can be considered technically operable (stage II and IIIA), or inoperable (stage IIIB, IV and IBC). For the last two decades, patients with inoperable LABC and IBC have been treated with increasing frequency with systemic therapy first, followed by regional therapy, either surgical resection or radiotherapy. Most treatment programs also included adjuvant systemic therapy. The majority of patients with LABC and IBC respond to primary chemotherapy, and most can be rendered disease-free initially. Local control rates exceed 80% with modern combined-modality treatment strategies. Since most tumors are downstaged, some patients can be treated with breast-conserving treatments. The optimal sequence of local and systemic treatments has not been defined. Combined-modality therapies improve the treatment and the outcome for patients with LABC. Whether the sequence of utilization of various treatments influences outcome remains to be established. The administration of systemic therapies first also provides a useful biological model to assess the effects of systemic treatments on the primary tumor and regional metastases, since these are available for serial non-invasive evaluation and sampling of tumor tissue.
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Affiliation(s)
- G N Hortobagyi
- Department of Breast and Gynecologic Medical Oncology, University of Texas M.D. Anderson Cancer Center, Houston 77030, USA
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36
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Forouhi P, Dixon JM, Leonard RC, Chetty U. Prospective randomized study of surgical morbidity following primary systemic therapy for breast cancer. Br J Surg 1995; 82:79-82. [PMID: 7881965 DOI: 10.1002/bjs.1800820127] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The influence of primary systemic therapy in treating operable breast cancer on postmastectomy morbidity rates was investigated. The contribution of other risk factors was assessed by multiple logistic regression. Seventy-nine eligible patients were randomly allocated, 39 to undergo immediate modified radical mastectomy, and 40 to receive initial cytotoxic or endocrine treatment followed by mastectomy. Postoperative wound seroma, infection and necrosis were recorded prospectively. Fourteen minor and six major complications occurred in 17 patients treated conventionally, while 14 patients developed 11 minor and six major complications after systemic therapy (P > 0.4). Median hospital stay was 8 days for both groups. Age, smoking, immediate breast reconstruction and the type of primary systemic treatment given were not independent predictors of complication risk. Obesity emerged as a significant risk factor for postmastectomy complications (P = 0.015). Primary systemic therapy does not increase the rate of morbidity after mastectomy.
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Affiliation(s)
- P Forouhi
- Edinburgh Breast Unit, Western General Hospital, UK
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37
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MacCallum J, Bartlett JM, Thompson AM, Keen JC, Dixon JM, Miller WR. Expression of transforming growth factor beta mRNA isoforms in human breast cancer. Br J Cancer 1994; 69:1006-9. [PMID: 8198961 PMCID: PMC1969445 DOI: 10.1038/bjc.1994.197] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Using an RNAse protection assay, expression of messenger RNA for isoforms of TGF-beta was determined in a series of breast cancers. Of 50 tumours, 45 (90%) expressed TGF-beta 1 mRNA, 39 (78%) expressed TGF-beta 2, and 47 (94%) expressed TGF-beta 3. Patterns of expression varied between different tumours: 37 (74%) cancers expressed all three TGF-beta isoforms, ten (20%) expressed only two isoforms and two expressed TGF-beta 1 alone. One sample showed no evidence of TGF-beta mRNA expression. Although most breast cancers expressed mRNA for at least one isoform of TGF-beta, there were differences in patterns of mRNA expression between individual tumours. The relatively small number of tumours examined precluded detailed analysis between expression and other clinical parameters, but a significant association was identified between one aspect of isoform expression and lymph node status, in that the majority of tumours expressing all three isoforms were associated with lymph node involvement, whereas tumours without one or more isoform were usually lymph node negative (P = 0.025 by Fisher's exact test).
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Biopsy
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Lobular/metabolism
- Carcinoma, Lobular/pathology
- Carcinoma, Lobular/surgery
- Female
- Gene Expression
- Humans
- Lymphatic Metastasis
- Mastectomy
- Middle Aged
- Neoplasm Invasiveness
- Polymorphism, Genetic
- RNA, Messenger/analysis
- RNA, Messenger/biosynthesis
- Receptors, Estrogen/analysis
- Transforming Growth Factor beta/biosynthesis
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Affiliation(s)
- J MacCallum
- University Department of Surgery, Edinburgh Royal Infirmary, UK
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38
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Thompson AM, Hawkins RA, Elton RA, Steel CM, Chetty U, Carter DC. pS2 is an independent factor of good prognosis in primary breast cancer. Br J Cancer 1993; 68:93-6. [PMID: 8318427 PMCID: PMC1968288 DOI: 10.1038/bjc.1993.292] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
In breast cancer, oestrogen regulated genes, such as pS2, may be expressed in well differentiated tumours with a good prognosis. We have examined pS2 mRNA expression in 78 primary, untreated breast cancers and related pS2 expression to disease behaviour and known prognostic factors. pS2 mRNA expression was detected in 25/78 (32%) of cancers and was significantly associated with a moderate/high oestrogen receptor content (P = 0.045, Chi Square test). pS2 mRNA expression was associated with freedom from disease at median 31 months clinical and radiological follow-up (P = 0.015, Fisher's exact test, odds ratio 8.6). Using multiple logistic regression analysis of six potential prognostic factors only pathological axillary node status (P < 0.01) and pS2 mRNA expression (P < 0.05) provided independent prognostic information. Furthermore, pS2 was associated with a good prognosis in the axillary node positive patients where only 1/13 (8%) with pS2 mRNA expression compared with 13/29 (45%) without detectable expression had recurrence of their disease. These data provides strong support for pS2 as a useful independent prognostic factor in primary breast cancer.
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Affiliation(s)
- A M Thompson
- University Department of Surgery, Royal Infirmary, Edinburgh, UK
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39
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Wiseman LR, McTavish D. Formestane. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential in the management of breast cancer and prostatic cancer. Drugs 1993; 45:66-84. [PMID: 7680986 DOI: 10.2165/00003495-199345010-00007] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Formestane (4-hydroxyandrostenedione) is an effective and competitive inhibitor of aromatase, the enzyme responsible for the conversion of androgens to estrone and estradiol. Significant reductions in plasma estradiol levels are observed following intramuscular administration of formestane to postmenopausal women with advanced metastatic breast cancer. Overall response rates to intramuscular formestane in these patients are approximately 25 to 30% and a further 20 to 30% of patients experience disease stabilisation during treatment. Response rates are improved in patients with hormone responsive tumours and in those who have responded to previous endocrine therapy. Soft tissue metastases generally show the best response to formestane treatment while visceral metastases (in particular liver) show a poor response. The median duration of response is usually between 7 months and 1 year. Formestane has been generally well tolerated in the relatively small clinical trials conducted to date with adverse effects reported in approximately 13% of patients following intramuscular administration. The most frequent adverse effects are local reactions at the injection site and systemic effects mainly related to the effect of the drug on the hormonal milieu. Thus, formestane is effective as a second-line endocrine treatment for advanced metastatic breast cancer in women with natural or artificially induced menopause, with apparent tolerability advantages over older agents such as aminoglutethimide; with wider study and experience it may yet challenge tamoxifen as a first-line endocrine therapy in metastatic breast cancer.
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Affiliation(s)
- L R Wiseman
- Adis International Limited, Auckland, New Zealand
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40
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Cappelletti V, Ruedl C, Miodini P, Fioravanti L, Coradini D, Di Fronzo G, Silvestrini R. Paracrine interaction in co-culture of hormone-dependent and independent breast cancer cells. Breast Cancer Res Treat 1993; 26:275-81. [PMID: 8251652 DOI: 10.1007/bf00665805] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A permeable solid support (Transwell Coll.) was used to develop serum-free co-cultures allowing paracrine interactions between hormone-dependent (MCF-7, ZR75.1) and hormone-independent (MDAMB-231, BT20) breast cancer cell lines. Both hormone-independent cell lines were able to stimulate the growth of the hormone-dependent lines, whereas the opposite was observed only in the case of BT20 co-culture with ZR75.1 cells. The cell growth stimulation observed in co-cultures could be abolished by the addition to the culture medium of an excess of transforming growth factor alpha (TGF alpha) or insulin-like growth factor I (IGF-I). Similarly, treatment with a neutralizing anti TGF alpha antibody impaired the growth stimulation exerted by hormone-independent cells on hormone-dependent cells. These results confirm the important role of paracrine interactions in control of the growth of human heterogeneous breast tumors and suggest that the main growth factors involved in such interactions are TGF alpha and probably some growth factors from the insulin-like growth factor family rather than IGF-I itself.
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Affiliation(s)
- V Cappelletti
- Oncologia Sperimentale C, Instituto Nazionale per lo Studio e la Cura dei Tumori, Milan, Italy
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41
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Gaskell DJ, Hawkins RA, Tesdale AL, Sangster K, Chetty U, Forrest AP. The differing predictive values of oestrogen receptor assays for large breast cancers. Postgrad Med J 1992; 68:900-3. [PMID: 1494511 PMCID: PMC2399488 DOI: 10.1136/pgmj.68.805.900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Thirty elderly patients with T3 or T4 breast cancer underwent a wedge biopsy for radioligand-binding assay (RLA) of oestrogen receptor (ER) activity. A second, separate group of 21 elderly patients with T3 and T4 breast cancers underwent fine needle aspiration biopsy (FNA) for immunocytochemical assay of ER (ER-ICA). All the women received tamoxifen as primary treatment and response was assessed by UICC criteria. Tumour ER concentration by RLA was correlated with both response (Spearman's R = + 0.52) and time to progression (R = + 0.76). Nine patients with receptor-rich tumours (> 100 fmol/mg protein) failed to show a response. However, the percentage of cells staining for ER by ER-ICA assay was much more strongly related to the likelihood of response (R = + 0.89); no patient with < 20% cells staining responded. Wedge biopsy and the biochemical determination of ER activity is of limited value in predicting the likely response to tamoxifen; ER-ICA assays on such tumours may be more informative.
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Affiliation(s)
- D J Gaskell
- University Department of Surgery, Royal Infirmary, Edinburgh, UK
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42
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Blankenstein MA, Szymczak J, Daroszewski J, Milewicz A, Thijssen JH. Estrogens in plasma and fatty tissue from breast cancer patients and women undergoing surgery for non-oncological reasons. Gynecol Endocrinol 1992; 6:13-7. [PMID: 1580162 DOI: 10.3109/09513599209081001] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Breast cancer tissue is able to maintain the tissue estradiol level in spite of the massive decrease in plasma estradiol associated with menopause, whereas fatty tissue from breasts with malignancies more closely reflects the changes in plasma. In the present study estrone and estradiol levels in fatty tissues from different origins were compared to evaluate the capacity of distant fatty tissues to act as estrogen reservoirs. Abdominal fat was obtained from 25 premenopausal and 20 postmenopausal women who underwent surgery for non-oncological reasons. Estrone and estradiol levels in these tissues were compared to those in breast fatty tissue from breast cancer patients. Plasma estrogen levels were not different in the two groups. In both groups, median plasma estradiol levels dropped sharply with menopause (from 363 to 40 pmol/l in breast cancer patients; from 280 to 45 pmol/l in the non-oncological patients; p less than 0.002), whereas a significant decrease in plasma estrone was observed only in the breast cancer patients (from 238 to 140 pmol/l; p less than 0.02). In premenopausal women, median estrone and estradiol levels in breast fatty tissue (1135 and 375 fmol/g, respectively) and abdominal tissue (1390 and 470 fmol/g, respectively) were not different. In postmenopausal women, however, significantly higher estrone levels (663 vs. 508 fmol/g; p less than 0.01) and estradiol levels (245 vs. 187 fmol/g; p less than 0.02) were found in abdominal fatty tissue. In view of the absolute estrogen levels in breast and abdominal fatty tissue and in plasma, we conclude, however, that it is unlikely that remote fat contributes substantially to the maintenance of estrogen levels in breast cancer tissue.
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Affiliation(s)
- M A Blankenstein
- Department of Endocrinology, Academic Hospital Utrecht, The Netherlands
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43
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Anderson ED, Forrest AP, Hawkins RA, Anderson TJ, Leonard RC, Chetty U. Primary systemic therapy for operable breast cancer. Br J Cancer 1991; 63:561-6. [PMID: 1827031 PMCID: PMC1972365 DOI: 10.1038/bjc.1991.131] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Eighty-eight patients presenting with operable breast cancer of 4 cm or greater in diameter (T2, T3, N0, N1, M0) have received primary systemic therapy. Response was assessed following 12 weeks of systemic therapy by linear regression analysis of changes in tumour volume. Definitive locoregional surgery (mastectomy n = 82, wide local excision n = 6) was performed on completion of systemic therapy (3-6 months). Response was observed in 24 (39%) of the 61 patients who received endocrine therapy; all 24 had tumours with an oestrogen receptor (ER) concentration of greater than or equal to 20 fmol mb-1 cytosol protein. Cytotoxic therapy was reserved for patients with tumours of ER concentration less than 20 fmol mg-1 cytosol protein (n = 27) or when endocrine therapy had failed (n = 20). Response was observed in 34 patients (72%). The overall survival rate at 3 years was 86%, with 81% remaining free from local relapse. We propose that the treatment policy outlined in this paper should now be tested against orthodox management by controlled randomised trial.
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Affiliation(s)
- E D Anderson
- University Department of Surgery, Royal Infirmary, Edinburgh, UK
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44
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Thompson AM, Kerr DJ, Steel CM. Transforming growth factor beta 1 is implicated in the failure of tamoxifen therapy in human breast cancer. Br J Cancer 1991; 63:609-14. [PMID: 2021547 PMCID: PMC1972347 DOI: 10.1038/bjc.1991.140] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Transforming growth factor-beta 1 (TGF-beta 1) is inhibitory for breast epithelial cells in vitro and treatment of breast cancer cell lines with tamoxifen results in a rise in TGF-beta 1 mRNA expression with associated inhibition of cell growth. To study whether these findings apply in vivo we examined TGF-beta 1 mRNA expression in an oestrogen-dependent mouse xenograft system following systemic treatment of the mice with tamoxifen. In agreement with in vitro studies. TGF-beta 1 mRNA expression was sustained at high levels and associated with a reduction in tumour size. A subsequent study of breast tumour tissue from 56 patients demonstrated high levels of TGF-beta 1 mRNA in 45 of the tumours. High expression was found to correlate with premenopausal status, but not with tumour oestrogen receptor content or other parameters. In a subgroup of 11 patients who had received tamoxifen therapy for 3 to 6 months prior to surgery, unexpectedly high levels of TGF-beta 1 mRNA were demonstrated in tumours increasing in size and unresponsive to tamoxifen. Data from this study indicate that in patients with breast cancer, TGF-beta 1 in the tumour may not behave as in vitro and xenograft studies have suggested. We speculate that failure of tamoxifen therapy may be due to failure of the autocrine inhibitory functions of TGF-beta 1 either alone or in combination with paracrine stimulation of stromal cells or angiogenesis and localised immunosuppression. Further studies of active TGF-beta 1, TGF-beta receptors and the interactions with other growth factors will be required to elucidate the precise role of TGF-beta 1 in human breast cancer and in the failure of tamoxifen therapy.
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Affiliation(s)
- A M Thompson
- Department of Surgery, Royal Infirmary, Edinburgh, UK
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45
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Chrisp P, Goa KL. Goserelin. A review of its pharmacodynamic and pharmacokinetic properties, and clinical use in sex hormone-related conditions. Drugs 1991; 41:254-88. [PMID: 1709853 DOI: 10.2165/00003495-199141020-00008] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Goserelin is a synthetic analogue of gonadotrophin-releasing hormone (GnRH) [luteinising hormone-releasing hormone (LHRH); or gonadorelin] which stimulates gonadotrophin and sex hormone release in the short term, and then causes suppression with continued administration. Goserelin is given as a subcutaneous biodegradable depot incorporating 3.6 mg of the drug, which is released continuously at an average rate of 120 micrograms/day over 4 weeks. Monthly goserelin depot therapy produces partial disease remission or stabilisation in about 75% of men with previously untreated prostatic cancer, a rate equivalent to that achieved with orchidectomy or diethylstilbestrol (stilboestrol). The response to goserelin is more rapid than to diethylstilbestrol, and goserelin is better tolerated. About 30 to 45% of premenopausal women with breast cancer responded to goserelin using objective assessment criteria, suggesting comparability to ovariectomy. In benign hormone-dependent conditions, preoperative goserelin aids surgical removal of uterine leiomyoma (fibroids) and reduces blood loss, and 6 months of therapy relieves the signs and symptoms of endometriosis. The elevation in testosterone at the beginning of goserelin therapy can result in disease 'flare' in men with prostate cancer, and sex steroid suppression with continued treatment results in hot flushes and loss of libido in most patients. Thus, goserelin is an effective alternative to surgery or estrogen therapy in prostatic cancer palliation, and possibly to ovariectomy in premenopausal breast cancer. Other gynaecological conditions reliant on the pituitary-gonadal axis also appear amenable to hormone manipulation with goserelin.
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Affiliation(s)
- P Chrisp
- Adis Drug Information Services, Auckland, New Zealand
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46
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Hawkins RA, Tesdale AL, Anderson ED, Levack PA, Chetty U, Forrest AP. Does the oestrogen receptor concentration of a breast cancer change during systemic therapy? Br J Cancer 1990; 61:877-80. [PMID: 2372489 PMCID: PMC1971691 DOI: 10.1038/bjc.1990.196] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The effect of systemic therapy on tumour oestrogen receptor (ER) concentration has been studied in 88 patients with large, operable, primary tumours (total 89) of the breast. In 26 patients, tumour was not available for study on one occasion (usually post-treatment). Forty-five patients were treated initially by endocrine therapy but, of these, 13 who had failed to respond went on to receive chemotherapy also. Seventeen patients with low concentrations of ER (less than 20 fmol mg-1 protein) were treated directly by chemotherapy. Patients underwent an incisional biopsy for confirmation of diagnosis and determination of pre-treatment ER by radioligand binding assay, followed by systemic therapy for 3 months (or 6 months for both endocrine and cytotoxic therapies). Response was assessed clinically and mammographically before mastectomy. ER concentration was then determined in the post-treatment tumour specimen. No significant change in ER concentration was seen in any treatment group except when the patients had received tamoxifen; there, receptor concentration fell to very low levels, presumably due to interference with the assay. There was no relationship between tumour response to systemic treatment and change in ER concentration. It is concluded that changes in ER concentration are unlikely to play a major role in the early response of breast tumours to systemic therapy.
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Affiliation(s)
- R A Hawkins
- University Department of Surgery, Royal Infirmary of Edingburgh, UK
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