Women who present with new breast cancer and synchronous metastases have traditionally been treated with systemic agents, with no specific therapy for the primary tumor unless local symptoms require palliation. However, a number of retrospective analyses of survival outcomes in these patients show that surgery for the primary tumor is associated with prolongation of survival. These studies suggest the possibility that local therapy for the primary tumor provides value beyond palliation of symptoms and points to the need for prospective data to guide treatment plans for women with de novo metastatic breast cancer. The coherence of the available data is improved by the findings that surgical resection of the primary tumor is of value only when free surgical resection margins are achieved, and that maintenance of local control at the primary site is associated with a survival advantage. Nevertheless, many questions remain, including the optimal timing of surgery for the primary tumor, whether the potential benefit applies only to women with favorable metastatic sites (e.g. bone-only metastases), and whether local radiotherapy should follow surgical treatment of the primary tumor if this is elected. There is also a lack of data addressing the value of axillary surgery in the metastatic setting. These substantial knowledge gaps limit our ability to deploy optimal use of therapeutic modalities for a patient population that reaches large numbers world-wide, and among whom survival duration is increasing due to more effective systemic therapy.

Breast cancer is the most common malignancy among women worldwide, and a quarter of all breast cancers are diagnosed in premenopausal women. Adjuvant chemotherapy is well established as the therapy of choice for hormone receptor-negative breast cancers. Historically, ovarian ablation substantially inhibited the progression of hormone-responsive breast cancer. Current adjuvant treatment options for premenopausal patients with hormone receptor-positive breast cancer include endocrine therapy and chemotherapy. Pharmacologic ovarian suppression alone has limited efficacy in the adjuvant setting, but it offers good clinical outcomes when combined with tamoxifen or chemotherapy. In recent years, aromatase inhibitors (AIs) have become the endocrine therapy of choice in postmenopausal women with hormone-responsive breast cancer, but their efficacy in the premenopausal setting is yet to be established. However, in a large, phase III randomized study (Austrian Breast and Colorectal Cancer Study Group Trial 12) that matured earlier this year, the combination of ovarian suppression and AI, anastrozole, did not show superior efficacy compared with ovarian suppression plus tamoxifen, but was associated with fewer serious adverse effects in premenopausal women with early stage hormone-responsive breast cancer. Data from ongoing and future trials will help to further define the role of ovarian suppression and AIs in the adjuvant setting for premenopausal breast cancer.

Use of perioperative anti-HER2 therapy presents an opportunity to use a therapy which has been shown to be effective in the adjuvant setting early in the course of a patient’s primary treatment, to assess tumour response in vivo using biomarkers and to potentially improve outcome by suppressing the growth stimulus to cancer cells that is thought to occur due to surgery. Biomarkers measured both before and after a short period of preoperative therapy may offer important predictive and prognostic information that can guide future therapy and follow-up. However, the safety and value of perioperative therapy in this context has not been established and its investigation should therefore be conducted within the context of a randomised, controlled trial. Such a trial, EPHOS-B, will shortly commence in UK alongside POETIC, a parallel trial of perioperative therapy in hormone receptor positive postmenopausal breast cancer.

Delivering bad news to patients being evaluated for and diagnosed with breast cancer requires a unique blend of medical knowledge, compassion, and sensitivity. Although many of the techniques involved are intuitive, one can enhance these skills by incorporating a few simple concepts into the patient encounter. By combining these with an understanding of appropriate responses to possible patient reactions to the news, one can create a more effective groundwork for the patient’s recovery on both physical and emotional levels.

Phyllodes tumors of the breast are rare fibroepithelial neoplasms with variable malignant potential. Treatment is primarily surgical; the use of radiation therapy is controversial. Here, we present the case of a 29-year-old female with a histologically malignant phyllodes tumor of the breast initially treated with wide local excision. At 18 months following surgery the patient experienced a local recurrence, which displayed sarcomatous degeneration on pathological examination. The patient subsequently underwent a total mastectomy and adjuvant radiation therapy. We discuss the decision to employ radiation therapy in the management of the patient's tumor.

The most important predictor of outcome for women with early stage breast cancer is the presence or absence of metastases in the axillary lymph nodes. In the era of sentinel lymph node biopsies and improved pathology techniques, micrometastatic disease can be diagnosed. The question of whether or not to treat these women as if they have nodal disease remains in doubt. In order to further explore this topic, we identified two cases of women with nodal micrometastases at our institution. A literature review of PUBMED and SABCS abstracts was then performed. In this article, we discuss our results and the emerging clinical debate about the management of nodal micrometastases.

Angiogenesis, or new vessel formation, plays a key role in the process of tumor growth and metastasis in breast cancer. Recent large phase-III trials (E2100 and AVADO) demonstrate the clinical utility of bevacizumab in combination with front-line taxane-based chemotherapy in patients with metastatic breast cancer, leading to its recent approval in the United States and Europe. Several other anti-angiogenic strategies against vascular endothelial growth factor are in various phases of clinical development. This paper reviews the data on bevacizumab in metastatic breast cancer and other anti-angiogenic strategies on development in breast cancer.