Treatment may be curative or palliative. Curative treatment is advised for clinical stage I, II, and III disease. Patients with locally advanced (T3, T4) and even inflammatory tumors may be cured with multimodality therapy, but in most patients, palliation is all that can be expected. Palliative treatment is appropriate for all patients with stage IV disease and for previously treated patients who develop distant metastases or who have unresectable local cancers.
The growth potential of tumors and host resistance factors vary widely from patient to patient and may be altered during the course of the disease. The doubling time of breast cancer cells ranges from several weeks in a rapidly growing lesion to a year in a slowly growing one. Assuming that the rate of doubling is constant and that the neoplasm originates in one cell, a carcinoma with a doubling time of 100 days may not reach clinically detectable size (1 cm) for about 8 years. Rapidly growing cancers have a much shorter preclinical course and a greater tendency to metastasize by the time a breast mass is discovered.
The long preclinical growth phase and the tendency of breast cancers to metastasize have led clinicians to believe that most breast cancer is a systemic disease at the time of diagnosis. Although it may be true that breast cancer cells are released from the tumor prior to diagnosis, variations in the host–tumor relationship prohibit the growth of disseminated disease in many patients. Clearly, not all breast cancer is systemic at the time of diagnosis. For this reason, a pessimistic attitude concerning the management of breast cancer is unwarranted. Most patients can be cured.
Board Review Questions
1. With respect to inherited breast cancer, which of the following are true?
A. Most newly-diagnosed breast cancers in women are related to either BRCA-1 or BRCA-2 positivity.
B. Early age of onset, multiple primary tumors, and bilateral cancers are typical in inherited breast cancer.
C. The lifetime risk of developing breast cancer if carrying a BRCA-1 or BRCA-2 gene mutation is approximately 50%
D. Patients carrying the BRCA-1 or BRCA-2 gene should have a prophylactic bilateral mastectomy before the age of 25 if possible.
E. Careful surveillance with monthly breast self-examination, annual physician physical examination, and total breast ultrasound will minimize risk associated with a strong pedigree of inherited breast cancers.
2. Following a needle localized excisional biopsy for microcalcifications, pathology is found to be fibrocystic changes associated with sclerosing adenosis and ductal hyperplasia. There is no atypia noted; however, the report also states that there is LCIS present. You discuss with your patient
A. that she needs at a partial mastectomy followed by radiation therapy
B. that she would benefit from a mirror biopsy because this disease is bilateral
C. that she has a future cancer risk of 1% per year
D. that there is no known therapy to help her reduce her risk and she should have close follow-up
E. that bi-yearly mammograms would be the best way to detect further LCIS
3. A 65-year-old female presents with a large (5 cm) mass in her right breast with overlying ulceration of the skin. She is noted to have several enlarged, mobile axillary lymph nodes on examination. She is subjected to a core biopsy which confirms the impression of invasive ductal carcinoma of the breast. Her management should begin with
B. sentinel lymph node biopsy
C. systemic chemo or hormonal therapy
D. radiation therapy
E. alternative therapy
1. The correct answer is B. Early age of onset, multiple primary tumors, and bilateral cancers are typical in inherited breast cancer
2. The correct answer is C. that she has a future cancer risk of 1% per year
3. The correct answer is C. systemic chemo or hormonal therapy