Treatment results in mammary carcinoma stages I-IV

The role of histologic grading in the prognosis of patients with carcinoma of the breast: is this a neglected opportunity?

BACKGROUND

Quantified grading of breast carcinoma through histologic analysis has been practiced for many years, but generally has not been used as an aid in treatment decision-making.

METHODS

A representative sample of the literature is reviewed and discussed.

RESULTS

The literature overwhelmingly confirms that histologic features suitable for grading provide important prognostic information at all stages of the disease, but there is no uniformly agreed on methodology for the application of this information. Disagreement still exists as to its validity and it is often ignored.

CONCLUSIONS

It appears reasonable that serious attempts be made to overcome the perceived problems with the grading of breast carcinoma and to develop a consensus regarding a methodology for quantifying this well established index of the virulence of the disease that is comparable to the consensus reached in the American Joint Committee on Cancer staging of the extent of disease. This information then could be used in the design of clinical trials. [See editorial counterpoint on pages 1703-5 and reply to counterpoint on pages 1706-7, this issue.]

A suggested follow-up time for breast cancer patients

The data for this study, consisting of 300 females treated for breast cancer in 1951-1961, were evaluated in order to ascertain when excess mortality from breast cancer disappears and what would be an appropriate follow-up period for investigational purposes. The clinical stages of the patients were classified as follows: 23.3%, stage I; 49%, stage II; 20.3%, stage III and 7.3%, stage IV. Halsted's radical mastectomy was performed in 79.7% of the cases. Every patient was given radiotherapy. Two hundred and ninety-eight patients could be followed until death or up to the present. Forty-five patients (16%) were still alive. The survival rate over a 20-year period for the various stages was as follows: stage I, 46.1%; stage II, 22.7% and stage III, 10.9%. Only 26% of the patients with stage I died of breast cancer, while the respective figures for stage II were 57% and stage III, 70%. The death rate from the cancer diminished with time in every stage especially 10 years after primary treatment. After this the observed survival rate curves were almost parallel with the expected curves. Our data show that for follow-up studies a 5-year follow-up is good and a 10-year follow-up is very good to show the trend in the treatment of breast cancer.

Subrenal capsule assay in human breast cancer. Response to cytostatic drug combinations and correlation with receptor status

The subrenal capsule assay (SRCA) was used to study the sensitivity of breast cancer to cytostatic drug combinations. The results were compared with steroid receptor status. Forty-five of 46 SRCAs (98%) were macroscopically evaluable. However, a histological study implied that the transplants should also be evaluated histologically, because in only 14/21 (67%) of the control SRCAs examined were histologically viable tumor cells seen. An inflammatory cell reaction was noticed in half of the cases. In the groups treated with cytostatics only 3/21 (14%) had vital tumor cells, whereas inflammation was evident in 4/21 (19%) of the cases. The rate of resistance to A + CTX was 30%. By testing several drug combinations against each tumor the rate of chemoresistance was reduced to 10%. The differences between A + CTX and the best combination were statistically significant (P less than 0.05). Of the tumors 79% were ER-positive and 67% PR-positive. Receptor-negative tumors tended to be more sensitive to cytostatics than receptor-positive tumors (100 vs 85%). The difference was not, however, statistically significant. It can be concluded that the SRCA under standardized conditions is a good method for studying the response of individual breast cancers to chemotherapy.

Cytophotometrical and biochemical characterization of nonpalpable, mammographically detected mammary adenocarcinomas

Fifty nonpalpable, mammographically detected, invasive breast carcinomas were analysed with respect to DNA distribution pattern, steroid receptor content, and histopathological criteria. No significant histomorphological differences were found as compared to palpable breast carcinomas. In contrast, DNA distributions of palpable and nonpalpable tumors differed. Ninety percent of these relatively small breast carcinomas were found to exhibit nuclear DNA amounts within the diploid and tetraploid regions of normal breast epithelium. In earlier findings in palpable breast carcinomas, 55% are of the diploid-tetraploid type. The mean cellular content of the estrogen receptor was 1.0 fmole/microgram DNA in this group of mammographically detected carcinomas, which is significantly higher than in routinely detected, ie, larger, breast carcinomas. It is suggested that, despite the histomorphological findings, nonpalpable, mammographically detected breast carcinomas are dominated by biologically highly differentiated, slowly proliferating carcinomas with a favourable prognosis.

Prophylactic low-dose post-operative orthovoltage radiotherapy in stage II breast cancer

Between the years 1974 and the beginning of 1977, 199 patients with stage II infiltrating duct carcinoma of the breast were treated with post-operative radiation, using a 250 kVp X-ray machine. Three treatment schedules were used consisting of 22, 26.2 and 29.6 Gy (2200, 2620 and 2960 rad) total tumour dose, calculated at 2 cm depth, with 5, 3 and 3 fractions a week respectively. The frequency of local recurrences, mainly in the chest wall, were 20.3%, 8.3% and 8.1% respectively. The latter two frequencies were not different from those reported for the commonly used high dose treatments of 45-60 Gy (4500-6000 rad) delivered either as given doses or tumour doses. An approximate 70% five year survival rate was similar in the three groups and does not differ from results observed with high doses. Low dose treatment is advantageous, because it has fewer complications and it can be delivered in a smaller number of sessions, making it more convenient to the patient, without loss of efficacy. The results presented of the low dose treatment may reflect the existence of an optimal dose level of radiation.

Influence of age on outcome in breast carcinoma

The effect of age on outcome was analysed in an unselected series of 1730 breast carcinoma patients reported from Stockholm county to the Swedish Cancer Registry during 1961-1963. The follow-up time was 18 to 21 years. Patients aged less than 50 years at diagnosis fared better than those who were older (p less than 0.05) but the difference was only significant during the period 0-9 years (p less than 0.001). No significant differences in survival were observed between separate age groups when patients in a random sample consisting of 389 cases were divided by histopathologic axillary node status. The main cause of the demonstrated age effect thus seems to have been a more favourable tumour stage distribution among the young patients. It is concluded, however, that a comprehensive analysis of the effect of age on the outcome of breast carcinoma would require a more detailed stage grouping than, in practice, is available in an unselected series of patients from a whole country or region.