Psychiatric consultation and supportive psychotherapy provide many benefits for women with breast cancer including an opportunity to address existential, physical, emotional, social, psychosexual and relationship (family and others) concerns. The psychiatrist is a source of meaningful information and helps the patient challenge pessimistic thoughts and consider life, health, family and career priorities. The management of psychiatric symptoms and the treatment of side effects helps promote adherence to cancer treatment.

The use of three-dimensional conformal external beam accelerated partial breast irradiation (3D conformal APBI) to deliver hypofractionated adjuvant radiation treatment to the region of the breast at highest risk for developing a local recurrence after lumpectomy is reviewed. Potential advantages of a 3D conformal radiation therapy approach for APBI compared to brachytherapy include improved dose homogeneity within the target volume and a non-invasive method for treatment delivery. Data from several early studies using 3D conformal APBI from New York University, William Beaumont Hospital, RTOG 0319, and Massachusetts General Hospital demonstrate technical feasibility, satisfactory early cosmetic outcome, and acceptable recurrence rates. To determine whether APBI provides equivalent local tumour control in the breast compared to conventional whole breast irradiation in the local management of early stage breast cancer, the first phase III randomized study of conventional whole breast irradiation vs. partial breast irradiation was opened conjointly by the NSABP and RTOG in March 2005. The results of this study will determine future directions in the treatment of early stage breast cancer, and, will help to define the role of APBI in breast conservation therapy.

Breast cancer is a multifactorial disease that is triggered by gene–environment interactions. Epidemiological research has identified alcohol consumption as a significant non-hormonal-related and consistent risk factor, and is thus a preventable cause of breast cancer. The reasons why alcohol drinking increase breast cancer risk are unclear, and several hypotheses exist. The perturbation of estrogen metabolism and response appears to one mechanism underlying the association. Alcohol consumption also increases breast density in postmenopausal women and affects sex steroid levels. Other plausible mechanisms include: (1) mutagenesis by acetaldehyde, which is a metabolite of ethanol; (2) by enhancing the susceptibility of the mammary gland to carcinogenesis by affecting DNA repair, stimulating cell proliferation or altering mammary gland structural development; (3) influencing the disposition and function of essential nutrients or dietary factors considered cancer protective (e.g. affecting folate and one-carbon metabolism pathways); (4) inducing genome instability and DNA damage; and (5) inducing oxidative damage via ethanol or estrogen metabolism. To better understand the etiological nature of the effect of alcohol on breast carcinogenesis, further studies at the cellular and molecular levels on the interaction between ethanol and other risk factors, estrogen, carcinogens are needed.

Citation of original article:

K. Kerlikowske, J. Shepherd, J. Creasman, J. A. Tice, E. Ziv, S. R. Cummings. Are breast density and bone mineral density independent risk factors for breast cancer. Journal of the National Cancer Institute 2005; 97(7): 368–74.

Abstract of the original article

Background: Mammographic breast density and bone mineral density (BMD) are markers of cumulative exposure to estrogen. Previous studies have suggested that women with high mammographic breast density or high BMD are at increased risk of breast cancer. We determined whether mammographic breast density and BMD of the hip and spine are correlated and independently associated with breast cancer risk. Methods: We conducted a cross-sectional study (N = 15 254) and a nested case-control study (of 208 women with breast cancer and 436 control subjects) among women aged 28 years or older who had a screening mammography examination and hip BMD measurement within 2 years. Breast density for 3105 of the women was classified using the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) categories, and percentage mammographic breast density among the case patients and control subjects was quantified with a computer-based threshold method. Spearman rank partial correlation coefficient and Pearson's correlation coefficient were used to examine correlations between BI-RADS breast density and BMD and between percentage mammographic breast density and BMD, respectively, in women without breast cancer. Logistic regression was used to examine the association of breast cancer with percentage mammographic breast density and BMD. All statistical tests were two-sided. Results: Neither BI-RADS breast density nor percentage breast density was correlated with hip or spine BMD (correlation coefficient = −.02 and −.01 for BI-RADS, respectively, and −2.06 and .01 for percentage breast density, respectively). Neither hip BMD nor spine BMD had a statistically significant relationship with breast cancer risk. Women with breast density in the highest sextile had an approximately threefold increased risk of breast cancer compared with women in the lowest sextile (odds ratio: 2.7; 95% confidence interval: 1.4–5.4); adjusting for hip or spine BMD did not change the association between breast density and breast cancer risk. Conclusion: Breast density is strongly associated with increased risk of breast cancer, even after taking into account reproductive and hormonal risk factors, whereas BMD, although a possible marker of lifetime exposure to estrogen, is not. Thus, a component of breast density that is independent of estrogen-mediated effects may contribute to breast cancer risk.

In breast cancer, oligometastatic disease is a controversial concept. Generally, solitary pulmonary lesions are detected on chest imaging made for other reasons (unintentionally). The majority of these pulmonary lesions in breast cancer patients prove to be unrelated (bronchogenic carcinoma or benign lesions), 33–40% are in fact breast cancer metastases. Only a small number of breast cancer patients (0.4–1%) will have potentially resectable isolated metastasis to the lung.

Controlled studies comparing pulmonary metastasectomy to systemic therapy or best medical care are lacking. Overall survival (OS) data in patients who underwent metastasectomy are favourable despite the high incidence of recurrences. Long-term survival is seen primarily in patients with only one or two lesions and long initial disease-free interval. Radical resections with unnecessary loss of pulmonary parenchyma should be avoided, since there is no benefit of such resection in terms of survival and the incidence of complications is higher.

Foremost justification of surgical resection for lung lesions in breast cancer patients is differentiation of metastatic breast cancer from new primary lung cancer. The survival impact of pulmonary resection in ‘oligometastatic’ breast cancer is probably limited and attempts should be made to limit the amount of tissue removed.

Breast cancer and its treatments can cause sexual dysfunction in up to 90% of women with the disease. Front line care providers often do not have the time or training to focus on this quality of life issue and the private nature of the topic can prevent women from pursuing help. By setting up a clinic specifically devoted to sexuality issues, breast cancer treatment centers can provide a place to address these issues and help patients deal with the after-effects of their treatment. As breast cancer survivor rates and disease-free intervals increase, the demand for a service that supports women returning to as near-normal a life as possible will only grow.

The estrogen receptor-alpha (ER-α) is a Type I nuclear receptor that is over-expressed in the majority of human breast cancers and plays a significant role in the development and progression of these cancers. As estrogen plays important roles in the etiology of breast cancer and the growth of established ER-α expressing cancers, intense interest has been generated in understanding the mechanisms by which ER-α signaling is regulated physiologically and using this knowledge to develop interventions to inhibit ER-α signaling. These efforts have met with some success in the development of pharmacologic agents that can reduce breast cancer risk, prevent recurrence of established cancers, and treat advanced cancers with considerably less side effects than cytotoxic chemotherapy. Here, we will review some of the mechanisms that operate to inhibit ER-α signaling and describe how pharmacologic agents and dietary factors interact with ER-α to block its activity. In the process of reviewing these mechanisms, we will highlight their clinical implications.

Radiation therapy is an important part of the modern multimodality treatment of breast cancer, and in the past decade has had an increasing role in the treatment of patients at intermediate to high risk for local-regional recurrence after mastectomy. During the same time period, a less radical surgical approach to mastectomy has developed that is more compatible with reconstruction, and a greater number of young patients diagnosed due to screening who are more motivated and candidates for the procedure. This has led to an increased need to consider the special implications of combining radiation with breast reconstruction. This review will focus on reconstruction by tissue expander and breast implants. A multidisciplinary approach to management is needed that includes a team of a plastic surgeon, and radiation, surgical and medical oncologists. Experience with implant reconstruction and radiation in the past decade has been associated with relatively high rates of complications and/or implant loss compared with unirradiated patients. However, newer techniques of radiation, and improved patient selection and coordination between the multidisciplinary team offer the promise of low complication rates and good or excellent cosmetic results for most patients in the future.

With advanced detection methods now allowing cancers to be found at earlier and earlier stages, new treatment methods to deal with these early stage cancers are also emerging. Radioguided occult lesion localisation (ROLL), a technique pioneered in 1996, is a useful method for localisation of impalpable breast tumours with results superior to those obtained by wire localisation and comparable to those achieved by surgery of palpable lesions. ROLL allows for the precise localisation necessary to optimise the cosmetic outcome in breast conserving surgery without jeopardising sufficient free tissue margins. ROLL can also be used in conjunction with sentinel node biopsy (SNB) using either the same or different radioactive tracer. For all these reasons, ROLL is an important development in breast cancer treatment.

A large number of studies in the last three decades have identified only a handful of biological features in the evolution of human premalignant breast lesions (PBL). They have shown that PBL have a positive growth balance, which may be driven/regulated by oestrogen receptor, erbB-2, and p53. There is marked genetic diversity in PBL, and use of newer technologies such as SAGE, DNA microarrays, and high-throughput proteomics will significantly improve our understanding of evolution of PBL over the next decade.

Kok et al.Breast Cancer Research and Treatment 4 March 2008 [Epub ahead of print].

With an aging population, the management of elderly patients with breast cancer is recognised as an area of increasing concern. This population, however, represents a heterogeneous group whom, on the basis of age alone should not be denied any appropriate interventions in the management of their breast cancer. This article reviews the current issues in treating these patients and the paucity of evidence in this setting.

Increasing number of small, early-staged breast cancers are detected by screening mammography. Diagnosis and determination of the prognostic factors may be made by either ultrasound (US) or stereotactically guided needle biopsy. Approximately 2000 stereotactic tables are installed at various medical centers throughout the United States and a significant number in other countries where breast cancer is common. Many surgeons and interventional radiologists are trained in the use of this technology for diagnostic purposes. Employing the same technology, these physicians may be trained to treat selected breast cancers with laser energy percutaneously. Experimental and clinical reports to-date indicate the technique to be safe. High-resolution imaging modalities including grayscale and color Doppler US, magnetic resonance imaging, mammography and needle biopsy, when necessary, will confirm the tumor kill. Newer imaging modalities such as magnetic resonance spectroscopy may also provide additional confirmation for total tumor ablation.

Since clinical trials have demonstrated that breast conservation is safe and effective for treatment of invasive breast cancer, there has been considerable disagreement and controversy about what constitutes an acceptable margin in breast cancer. Dogmatic adherence to a set margin for all patients may cause a higher mastectomy rate than necessary, and thus it is important to understand how various clinical and pathologic factors affect local recurrence and outcome. This review discusses that controversy, as well as what factors should be considered when evaluating patients on an individual basis.