Systemic therapy in patients with node-negative breast cancer. A commentary based on two National Surgical Adjuvant Breast and Bowel Project (NSABP) clinical trials

A Short History of Bernard Fisher's Contributions to Randomized Clinical Trials

Dr. Bernard Fisher (1918-2019) was an early proponent of evidence-based medicine using the mechanism of prospective, multicenter, randomized clinical trials to test biological and clinical hypotheses. In this article, I trace how his early scientific work in striving to understand the nature of cancer metastasis through animal experiments led to a new, testable, clinical hypothesis: that surgery to remove only the tumor and a small amount of tissue around it was as effective as the more disfiguring operations that were then the standard treatment. Fisher's work with the National Surgical Adjuvant Breast and Bowel Project (NSABP) using large, randomized clinical trials to demonstrate the veracity of this hypothesis led to a new paradigm in which the emphasis was placed on how systemic therapies used at an early stage of disease could effectively eradicate breast cancer for many patients. This new therapeutic approach led to the successful development of new treatments, many of which are widely used today. Ultimately, the new paradigm led to successfully preventing breast cancer in women who were at high risk for the disease but who had not yet been diagnosed with the disease. Throughout his entire career, Fisher championed the use of large prospective, randomized clinical trials despite criticism from many in the medical community who strongly criticized his use of randomization as a mechanism for testing clinical hypotheses. The approach he and the NSABP employed is still considered to be the highest standard of evidence in conducting clinical studies.

The use of genomic assays reduces rates of chemotherapy: a single-institution experience

INTRODUCTION

The National Institute for Clinical Excellence recommends the use of tumour profiling tests to guide adjuvant chemotherapy in breast cancer. The Oncotype DX™ score (Genomic Health) has superseded more traditional tools such as PREDICT in appropriate patients (ER + ve, HER2-ve, lymph node negative and with a Nottingham Prognostic Index [NPI] ≥ 3.4). The aim of this study was to see whether the introduction of Oncotype DX within our institution resulted in an overall reduction in rates of chemotherapy.

METHOD

Data was collected retrospectively using the Somerset Cancer Register, Pathology department databases and the institution's own online medical records system. Two groups were compared: (1) pre-oncotype (Jan 2012-Dec 2014) and (2) post-oncotype (Jan 2016-July 2018).

RESULTS

During the pre-oncotype period, 28/82 (34%) patients who would have been eligible for testing (patients who were ER + ve, HER2-ve, and a NPI ≥ 3.4) received chemotherapy compared to 34/135 (25%) who were sent for oncotype during the second study period (p = 0.157). For grade 3 cancers, and those aged under 50, the results were more marked: grade 3 pre-oncotype 23/43 (53%), post-oncotype 29/76 (38%) (p = 0.101), aged under 50 pre-oncotype 8/15 (53%), post-oncotype 10/31 (32%) (p = 0.197).

CONCLUSION

Within our institution, overall rates of chemotherapy have reduced since the introduction of Oncotype DX with the results more marked in subgroups of traditional indicators of tumour aggression. As genomic assays provide a more accurate prediction of the benefit of chemotherapy, its overall reduction has potential cost saving implications as well as reducing risk in patients who will derive little benefit.

Role of Metastatic Lymph Nodes to Totally Removed Lymph Nodes Ratio in Breast Cancer?

Aim

To determine prognostic ratio of metastatic lymph nodes to totally removed lymph nodes (MLN/TRLN) on overall and progression-free survival with diagnosis of breast cancer.

Material and method

Radiation Oncology department of Kayseri Training and Research Hospital, relationship of MLN/TRLN between prognosis and other prognostic factors was evaluated in T1-3 and N1-3 non-metastatic breast cancer patients.

Results

Two hundred female patients and 5 male patients with an average age of 56 years were enrolled in this study. Of all patients, 63.4% of the patients were postmenopausal and modified radical mastectomy was performed in 96.6% of them. While 93.2% of the patients were diagnosed with invasive ductal carcinoma, 52.7% of them had clinical N1 disease, 62% of them were staged as T2, 94% of them received chemotherapy and 57.1% of them received hormonal therapy. Metastatic lymph node ratio below 0.2 was 48.8%, between 0.21–0.65 it was 35.1% and above 0.65% it was 16.1%. Five-year Overall survival and progression-free survival rates were 76% and 58% respectively. Statistically significant difference was found between MLN/TRLN and age (p = 0.044), chemotherapy (p = 0.039), pathological lymph nodes (p <0.001) according to Pearson's Chi-Squared test. Factor affecting overall survival was Progesterone receptor status (p = 0.021) and for progression-free survival they were gender (p = 0.003) and human epidermal growth factor receptor 2 (p = 0.018). Univariate and multivariate analysis found that gender (p = 0.04, OR 5.9, CI: 1.7–19.6) and lymph node (p = 0.05, OR: 1.4, CI: 0.9–2.1) were significant factors affecting progression-free survival.

Conclusion

MLN/TRLN was shown to have no effect on prognosis in non-metastatic breast cancer patients due to small number of patients and short follow-up period.

Milestone clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP)

The National Surgical Adjuvant Breast and Bowel Project (NSABP) has made significant contributions in reducing the extent of breast surgery and in improving outcomes of patients with early-stage breast cancer through the conduct of large randomized clinical trials evaluating local and systemic therapy. In 2014, the NSABP merged with two other US National Cancer Institute-funded cooperative groups, the Radiation Therapy Oncology Group (RTOG) and the Gynecologic Oncology Group (GOG), to form NRG Oncology. The combined organization has 218 member institutions with more than 600 affiliate centers located throughout the United States, Canada, Puerto Rico, and other international sites. Over the past half century, the NSABP has entered more than 150,000 women into clinical trials of breast cancer treatment and breast cancer prevention. Many of these trials have been instrumental in establishing new standards of care for patients with breast cancer.

TBX2 represses CST6 resulting in uncontrolled legumain activity to sustain breast cancer proliferation: a novel cancer-selective target pathway with therapeutic opportunities

TBX2 is an oncogenic transcription factor known to drive breast cancer proliferation. We have identified the cysteine protease inhibitor Cystatin 6 (CST6) as a consistently repressed TBX2 target gene, co-repressed through a mechanism involving Early Growth Response 1 (EGR1). Exogenous expression of CST6 in TBX2-expressing breast cancer cells resulted in significant apoptosis whilst non-tumorigenic breast cells remained unaffected. CST6 is an important tumor suppressor in multiple tissues, acting as a dual protease inhibitor of both papain-like cathepsins and asparaginyl endopeptidases (AEPs) such as Legumain (LGMN). Mutation of the CST6 LGMN-inhibitory domain completely abrogated its ability to induce apoptosis in TBX2-expressing breast cancer cells, whilst mutation of the cathepsin-inhibitory domain or treatment with a pan-cathepsin inhibitor had no effect, suggesting that LGMN is the key oncogenic driver enzyme. LGMN activity assays confirmed the observed growth inhibitory effects were consistent with CST6 inhibition of LGMN. Knockdown of LGMN and the only other known AEP enzyme (GPI8) by siRNA confirmed that LGMN was the enzyme responsible for maintaining breast cancer proliferation. CST6 did not require secretion or glycosylation to elicit its cell killing effects, suggesting an intracellular mode of action. Finally, we show that TBX2 and CST6 displayed reciprocal expression in a cohort of primary breast cancers with increased TBX2 expression associating with increased metastases. We have also noted that tumors with altered TBX2/CST6 expression show poor overall survival. This novel TBX2-CST6-LGMN signaling pathway, therefore, represents an exciting opportunity for the development of novel therapies to target TBX2 driven breast cancers.

Ovarian function preservation with GnRH agonist in young breast cancer patients: does it impede the effect of adjuvant chemotherapy?

BACKGROUND

Concurrent endocrine therapy with chemotherapy had a concern of potential antagonism. However, gonadotropin-releasing hormone (GnRH) agonist has been used concurrently with chemotherapy to prevent premature ovarian failure for young breast cancer patients. The aim of this study was to determine the impact of concurrent use of GnRH agonists on relapse-free and overall survival, and to establish the oncologic safety of ovarian protection with GnRH agonists.

METHODS

Premenopausal women aged between 20 and 40 years who received adjuvant chemotherapy for breast cancer from January 2002 to April 2012 were classified into two groups; One treated with GnRH agonists for ovarian protection during chemotherapy, and the other without ovarian protection. A propensity score matching strategy was used to create matched sets of two groups with age, pathologic stage, hormone receptor, and Her2 status.

RESULTS

A total of 101 patients treated with concurrent GnRH agonist during chemotherapy were compared with 335 propensity score matched patients. Among them, 81.2% were younger than 35 years and 58.4% were hormone responsive. Survival analysis using stratified Cox regression showed that women treated with concurrent GnRH agonists had better recurrence-free survival (adjusted Hazard ratio 0.21, p = 0.009; unadjusted Hazard ratio 0.33, p = 0.034).

CONCLUSIONS

Ovarian protection using GnRH agonists can be safely considered for young women with breast cancer in terms of oncologic outcomes. Further studies are needed to assess the long-term outcomes of concurrent GnRH agonist use with chemotherapy.

Treatment of breast cancer in young women: do we need more aggressive therapies?

Breast cancer diagnosed in young patients has been reported to have a more aggressive biologic behaviour and to be associated with a more unfavorable prognosis compared with the disease in older patients. However controversies exist regarding the optimal treatment and if more aggressive therapies are really crucial in this population. Very young women with this disease are faced with personal, family, professional, and quality-of-life issues that further complicate the phase of treatment decision-making. Moreover it's mandatory in young patients to consider the impact of acute but also late toxicities in relation to long life-expectancy, too. Dose-dense and high-dose chemotherapy are two examples of more aggressive therapies that failed to show a clear beneficial in a feasible way compared to standard regimens also in young patients. The benefit evidenced in patients with ER-positive disease raises the hypothesis that efficacy of dose-intensive chemotherapy might simply be related to its endocrine effects. The study of the biology and of the oncogenic pathways should be a research priority so to aid management of young patients with breast cancer, and more important, to better tailor treatments that could be offered to young women or, simply to use better the modalities available today. For the time being, young age alone should not be a reason to prescribe more aggressive therapies and there are no evidence to recommend a specific chemotherapy regimen for young women.

Multiparametric magnetic resonance imaging, spectroscopy and multinuclear (²³Na) imaging monitoring of preoperative chemotherapy for locally advanced breast cancer

RATIONALE AND OBJECTIVES

The aim of this prospective study was to investigate using multiparametric and multinuclear magnetic resonance imaging during preoperative systemic therapy for locally advanced breast cancer.

MATERIALS AND METHODS

Women with operable stage 2 or 3 breast cancer who received preoperative systemic therapy were studied using dynamic contrast-enhanced magnetic resonance imaging, magnetic resonance spectroscopy, and ²³Na magnetic resonance. Quantitative metrics of choline peak signal-to-noise ratio, total tissue sodium concentration, tumor volumes, and Response Evaluation Criteria in Solid Tumors were determined and compared to final pathologic results using receiver-operating characteristic analysis. Hormonal markers were investigated. Statistical significance was set at P < .05.

RESULTS

Eighteen eligible women were studied. Fifteen responded to therapy, four (22%) with pathologic complete response and 11 (61%) with pathologic partial response. Three patients (17%) had no response. Among estrogen receptor-positive, HER2-positive, and triple-negative phenotypes, observed frequencies of pathologic complete response, pathologic partial response, and no response were 2, 5, and 0; 1, 4, and 0; and 1, 1, and 3, respectively. Responders (pathologic complete response and pathologic partial response) had the largest reductions in choline signal-to-noise ratio (35%, from 7.2 ± 2.3 to 4.6 ± 2; P < .01) compared to nonresponders (11%, from 8.4 ± 2.7 to 7.5 ± 3.6; P = .13) after the first cycle. Total tissue sodium concentration significantly decreased in responders (27%, from 66 ± 18 to 48.4 ± 8 mmol/L; P = .01), while there was little change in nonresponders (51.7 ± 7.6 to 56.5 ± 1.6 mmol/L; P = .50). Lesion volume decreased in responders (40%, from 78 ± 78 to 46 ± 51 mm³; P = .01) and nonresponders (21%, from 100 ± 104 to 79.2 ± 87 mm³; P = .23) after the first cycle. The largest reduction in Response Evaluation Criteria in Solid Tumors occurred after the first treatment in responders (18%, from 24.5 ± 20 to 20.2 ± 18 mm; P = .01), with a slight decrease in tumor diameter noted in nonresponders (17%, from 23 ± 19 to 19.2 ± 19.1 mm; P = .80).

CONCLUSIONS

Multiparametric and multinuclear imaging parameters were significantly reduced after the first cycle of preoperative systemic therapy in responders, specifically, choline signal-to-noise ratio and sodium. These new surrogate radiologic biomarkers maybe able to predict and provide a platform for potential adaptive therapy in patients.

The half century of clinical trials of the National Surgical Adjuvant Breast And Bowel Project

The supplanting of radical mastectomy by simple mastectomy and then by lumpectomy plus radiation, the use of adjuvant therapy to alter the natural course of breast and colorectal cancer, the use of tamoxifen for the prevention of breast cancer, and the dramatic improvement in survival demonstrated with the use of the monoclonal antibody trastuzumab in women with HER2-positive breast cancer are all the direct results of research that has been carried out over the past 50 years by the National Surgical Adjuvant Breast and Bowel Project (NSABP). This National Cancer Institute-supported clinical cooperative trials group based in Pittsburgh, PA, currently has 200 member institutions and 700 satellite centers located throughout the United States, Canada, Puerto Rico, and Ireland. The NSABP's mandate is to conduct large randomized phase III trials to evaluate therapies designed to improve the treatment and prevention of breast and colorectal cancer. Over the past half century, the NSABP has entered more than 150,000 patients and participants into clinical studies that have changed the treatment of colorectal cancer and have revolutionized the treatment and prevention of breast cancer.

Bayesian Hierarchical Multiresolution Hazard Model for the Study of Time-Dependent Failure Patterns in Early Stage Breast Cancer

The multiresolution estimator, developed originally in engineering applications as a wavelet-based method for density estimation, has been recently extended and adapted for estimation of hazard functions (Bouman et al. 2005, 2007). Using the multiresolution hazard (MRH) estimator in the Bayesian framework, we are able to incorporate any a priori desired shape and amount of smoothness in the hazard function. The MRH method's main appeal is in its relatively simple estimation and inference procedures, making it possible to obtain simultaneous confidence bands on the hazard function over the entire time span of interest. Moreover, these confidence bands properly reflect the multiple sources of uncertainty, such as multiple centers or heterogeneity in the patient population. Also, rather than the commonly employed approach of estimating covariate effects and the hazard function separately, the Bayesian MRH method estimates all of these parameters jointly, thus resulting in properly adjusted inference about any of the quantities.In this paper, we extend the previously proposed MRH methods (Bouman et al. 2005, 2007) into the hierarchical multiresolution hazard setting (HMRH), to accommodate the case of separate hazard rate functions within each of several strata as well as some common covariate effects across all strata while accounting for within-stratum correlation. We apply this method to examine patterns of tumor recurrence after treatment for early stage breast cancer, using data from two large-scale randomized clinical trials that have substantially influenced breast cancer treatment standards. We implement the proposed model to estimate the recurrence hazard and explore how the shape differs between patients grouped by a key tumor characteristic (estrogen receptor status) and treatment types, after adjusting for other important patient characteristics such as age, tumor size and progesterone level. We also comment on whether the hazards exhibit nonmonotonic patterns consistent with recent hypotheses suggesting multiple hazard change-points at specific time landmarks.

Role of antiestrogens and aromatase inhibitors in breast cancer treatment

This review explores the recent experience with, and the basis for, the use of selective estrogen receptor modulators to treat and prevent breast cancer. As new agents are unveiled, they will continue to be tested against tamoxifen. A number of new selective estrogen receptor modulators are in clinical development in an attempt to decrease the unwanted effects of tamoxifen. Raloxifene holds the promise of treating osteoporosis with the beneficial side effect of breast cancer prevention. Additionally, two different classes of hormonal agents, the aromatase inhibitors and estrogen receptor down-regulators, which have no estrogen-like properties at any site, appear to be promising new treatments for advanced breast cancer.

Breast cancer and human immunodeficiency virus: a report of 20 cases

Carcinoma of the breast is the most common malignancy in women in the United States. More than 40% of patients with human immunodeficiency virus (HIV) infection develop cancer during their illness, but breast cancer has seldom been reported. Twenty patients with breast cancer and HIV infection seen at the University of Miami/Jackson Memorial Hospital between January 1988 and August 2000 were retrospectively analyzed. Seventeen patients had a previous or concurrent diagnosis of HIV at the time of the breast cancer diagnosis. Their CD4 count ranged from 13-1126/microL (median, 309/microL). Most patients were premenopausal (16 of 20), with ages ranging from 31-61 years (median, 44 years). All stages of breast cancer were seen: ductal carcinoma in situ (2 patients), stage I (1 patient), stage II (9 patients), stage III (6 patients), and stage IV (2 patients). Ten tumors had estrogen receptors. Four of the 13 patients who underwent axillary lymph node dissection had abnormal lymph node findings, including 2 with follicular hyperplasia and 2 with caseating granulomas. Seven patients received chemotherapy with very poor tolerance. Estrogen receptor-positive patients were treated with tamoxifen. Of the 18 patients who presented with local disease, 7 have died: 2 of breast cancer, 4 of acquired immunodeficiency syndrome, and 1 of cardiac arrest. Nine patients remain free of disease (5 of them > 5 years) and 2 patients are alive with metastatic disease. Breast cancer in the HIV-positive population is similar to that seen in seronegative women. Most of the patients that are long-term survivors were treated with surgery and tamoxifen. The benefits of adjuvant chemotherapy are not clear.

Locoregionally recurrent breast cancer: incidence, risk factors and survival

Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR can suffer both local consequences and symptoms of metastatic disease, as LRR is an independent predictor of subsequent distant metastases. Much of the available data on LRR is derived from small, single institution, retrospective studies, so marked differences in the incidence rates for LRR, it's risk factors and subsequent systemic recurrence are reported. The purpose of this review was to try and collate this data in a format that would be useful for both clinicians and their patients.

Does sentinel lymphadenectomy improve staging and alter therapy in elderly women with breast cancer?

BACKGROUND

Routine axillary lymph node dissection (ALND) for elderly women with invasive breast cancer has been questioned because it rarely alters therapy yet carries a significant morbidity rate. Sentinel lymphadenectomy (SLND) improves axillary staging and alters therapy in women with T1 breast cancer, but it is not clear whether SLND alters therapy in elderly women with breast cancer.

METHODS

A prospective breast cancer data base was used to identify women 70 years old and older who underwent SLND for axillary staging of invasive breast cancer between 1991 and 1998.

RESULTS

There were 75 invasive breast cancers in 73 women. The mean patient age was 74.5 years (range, 70-90 years). Median tumor size was 1.4 cm (range, 0.1-6.2 cm). Of the 75 tumors, 42 (56%) had favorable primary characteristics; the remaining tumors had unfavorable characteristics. SLND was performed alone in 17 cases (23%) and was followed by completion ALND in 58 cases (77%). Positive lymph nodes were identified in 32 cases (43%); 26 (81.3%) were detected by hematoxylin and eosin stains, and 6 (18.7%) were detected by immunohistochemistry alone. Five patients (6.9%) received adjuvant chemotherapy. Seven patients (9.6%) received axillary/supraclavicular radiation for positive nodes. Ten (13.7%) of 73 patients had obvious alterations in therapy because of axillary nodal status. As a result of SLND, 3 (13.6%) of 22 patients with tumors 1.0 cm or smaller received tamoxifen, and 7 (15%) of 46 patients with tumors between 1.0 and 3.0 cm in size had changes in therapy. When patient and tumor characteristics were analyzed to determine relationships to therapeutic decision-making, nodal status was the variable most significantly associated with changes in therapy (P = .0001).

CONCLUSIONS

SLND improves axillary staging in elderly women with invasive breast cancer. Results of immunohistochemistry do not alter therapy in this group of individuals (P = .6367). In patients with small primary tumors, SLND alters therapy by increasing the number of patients receiving tamoxifen. In addition, SLND affects adjuvant systemic chemotherapy and regional radiotherapy in a significant number of patients with larger tumors, particularly tumors between 1.0 and 3.0 cm.

Image-guided core breast biopsy: a suitable method for preoperative biological characterization of small (pT1) breast carcinomas

Multiple prognostic indicators, namely histological grade and immunostaining for estrogen (ER) and progesterone receptors (PgR), MIB 1, bc1-2, and p53, were retrospectively determined on preoperative core biopsies from 75 patients with pT 1 breast carcinoma. The association of the preoperatively evaluated factors with those on the corresponding resected tumors (i.e. nodal status, histological grade, presence or absence of vascular invasion and necrosis) was assessed. In univariate analysis, histological grade on resected tumors was significantly associated with histological grade on core biopsy, p53 expression, MIB1 immunostaining. An inverse association was found between postoperative histologic grade and ER, PgR, and bc1-2. Necrosis was significantly associated with grade, p53, MIB1, and inversely with ER, PgR, and bc1-2. Nodal involvement and vascular invasion were significantly associated with MIB1. In multivariate analysis, histological grade and ER were the only independent core biopsy variables associated with postoperative histological grade and necrosis, respectively. This study showed that image-guided core biopsy is a suitable method that can be used to reveal some characteristics of the tumor biology in a preoperative stage.

Long-term tamoxifen citrate use and potential ocular toxicity

PURPOSE

To estimate the prevalence of abnormalities in visual function and ocular structures associated with the long-term use of tamoxifen citrate.

METHODS

A single-masked, cross-sectional study involving multiple community and institutional ophthalmologic departments was conducted with a volunteer sample of 303 women with breast cancer currently taking part in a randomized clinical trial to determine the efficacy of tamoxifen (20 mg/day) in preventing recurrences. Participants included women who had never been on drug (n=85); women who had taken tamoxifen for an average of 4.8 years, then been off the drug for an average of 2.7 years (n=140); and women who had been on tamoxifen continuously for an average of 7.8 years (n=78). Women were evaluated by questionnaire, psychophysical testing, and clinical examination to determine any abnormalities in visual function and the comparative prevalences of corneal, lens, retinal, and optic nerve pathology.

RESULTS

There were no cases of vision-threatening ocular toxicity among the tamoxifen-treated participants. Compared with nontreated participants, the tamoxifen-treated women had no differences in the activities of daily vision, visual acuity measurements, or other tests of visual function except for color screening. Intraretinal crystals (odds ratio [OR]=3.58, P=.178) and posterior subcapsular opacities (OR=4.03, P=.034) were more frequent in the tamoxifen-treated group.

CONCLUSIONS

Women should have a thorough baseline ophthalmic evaluation within the first year of initiating tamoxifen therapy and receive appropriate follow-up evaluations.

Is the negative prognostic value of high oestrogen receptor (ER) levels in postmenopausal breast cancer patients due to a modified ER gene product?

Recently, it was found that, among post menopausal breast cancer patients receiving no adjuvant therapy, the highest oestrogen receptor (ER) levels (ER++) as opposed to the intermediate ER levels (ER+) indicated a poorer prognosis in terms of recurrence-free survival (Thorpe et al. Eur J Cancer 1993, 29A, 971-977). In the present study, we confirm, in a series of 218 node negative, postmenopausal patients in whom ER was determined using a one-dose saturating method, that ER+ tumours have a more negative effect on disease-free survival (DFS) than ER+ tumours (P = 0.02). In another series of 87 ER positive, postmenopausal patients, we found a significant correlation (P = 0.04) between the ER level and ER+R ratio (ER protein/ER-specific mRNA): the higher the ER level, the more numerous the high ER+R ratio cases (ER+R > 1.5), reflecting an imbalance between the ER protein level and ER-specific mRNA. From these results, we hypothesise that high ER levels related to a high ER+R ratio suggest the presence of a modified ER gene product.

Short recurrence-free survival associated with high oestrogen receptor levels in the natural history of postmenopausal, primary breast cancer

The ability of oestrogen and progesterone receptor (ER and PgR, respectively) status to discriminate recurrence-free survival (RFS) among a cohort of consecutively accrued 952 postmenopausal patients has been studied. None of the cohort members investigated were treated with adjuvant therapy. Using a graduated scale of receptor status [low, intermediate and high receptor levels (< 10 vs. 10-107 vs. > or = 108 fmol/mg cytosol protein, respectively)] instead of the more commonly used dichotomous subdivision (positive vs. negative), ER level significantly discriminated between groups of patients with long vs. short RFS. Contrary to our expectations, patients with highest ER levels have as poor a prognosis as ER-negative patients, while patients with intermediate ER levels have longest RFS. The group of patients with ER levels > or = 108 fmol/mg cytosol protein comprises 47% of the cohort. The independent significance of overexpression of ER as a prognostic factor among this patient group is demonstrated in multivariate analysis where ER level is more significant than either grade of anaplasia or tumour size. PgR status did not significantly predict RFS among these patients. While the highest ER levels predispose for poorer prognosis among postmenopausal patients, it is precisely this group that experiences greatest benefit from adjuvant treatment with tamoxifen. Thus, patients who might otherwise go untreated due to their node-negative status can be readily identified and offered adjuvant treatment.

Tamoxifen in axillary node--negative breast cancer: multisystem benefits and risks

Adjuvant tamoxifen therapy is associated with modest improvement in disease-free and overall survival in women with invasive axillary node-negative breast cancer. The preponderance of data supporting these general conclusions are from trials in postmenopausal women; in premenopausal women data appear convincing regarding disease-free, but not overall, survival. Firm conclusions regarding magnitude of benefit related to presence of different prognostic factors cannot be drawn at present. In postmenopausal women tamoxifen appears to alter favorably some risk factors for cardiovascular diseases and osteoporosis, which are the most common causes of mortality or morbidity in older American women. Adjuvant tamoxifen is associated with a significantly reduced risk of second primary breast cancer. Major serious risks of tamoxifen therapy include depression, and possibly thrombophlebitis and uterine endometrial cancer. Symptomatic vasomotor and gynecological side effects are frequent. Decision making with women should include assessment of these multisystem benefits and risks.

Medical management of early-stage breast cancer

With improved screening and education, a greater proportion of breast cancer is detected at an early stage. Although the prognosis for many of these patients is excellent following definitive local therapy alone, some subsets of node-negative patients have a 30% chance of eventually developing metastatic disease that will be incurable with current therapy. Thus, an increasing proportion of early-stage patients are being offered some form of adjuvant therapy, with the expectation of improved relapse-free survival, and possibly improved overall survival. Efforts have been made to base the selection of patients for adjuvant therapy on specific prognostic factors. Meanwhile, the scope and complexity of putative prognostic factors continues to widen, and now includes such items as the presence of occult microscopic metastases, DNA ploidy and proliferative fraction, cytogenetic abnormalities, oncogene expression, growth factor receptors, and expression of hormonally regulated proteins. In addition, there is now a considerable range of options with regard to the composition, dose intensity, and sequence of multimodality therapy. Data regarding the classification, significance, and interpretation of prognostic factors is reviewed together with the development, current status, and recommendations regarding adjuvant therapy for patients with early-stage breast cancer. For 1991, the National Cancer Institute (NCI) has estimated that 175,000 new cases of breast cancer will be diagnosed in American women. It is also estimated that 44,500 women will die of breast cancer. Unfortunately, the age-adjusted death rate from breast cancer has shown no overall change from 1930 through 1987. However, effective screening techniques continue to identify an increasing percentage of early-stage tumors, which should exceed 50% of all new tumors in 1991. Ultimately, our understanding of environmental and genetic risk factors may identify new ways to reduce the impact of this disease. In the interim, development and application of effective systemic adjuvant chemotherapy and hormonal therapy has become increasingly important. There is no question that a greater proportion of patients with less extensive disease are now being offered some form of adjuvant therapy. Meanwhile, selection of patients for adjuvant therapy, and choice among specific adjuvant regimens, has remained controversial. Analysis of multiple prognostic factors is performed not only in the context of cooperative investigational trials, but more often in the offices of individual physicians caring for individual patients. Tumor biopsies can now be routinely sent to specialized laboratories for performance of complex assays with potential prognostic information, although interpretation of these results with reference to a specific patient is often uncertain.(ABSTRACT TRUNCATED AT 400 WORDS)