Recent advances in the management of primary breast cancers

The current concept of breast cancer treatment arises from Fisher's theory that operable breast cancer has distant micrometastasis at its very early stages. Since it is the presence of systemic diseases or micrometastasis that determines the final outcome, variation in local treatment would not affect survival. Fisher's theory led to a change in local treatment, from Halsted's radical mastectomy to breast-conserving therapy (BCT), and the introduction of adjuvant systemic treatment. As part of the job of surgery is replaced by radiation therapy in local control, the efficacy and side effects of radiation should be carefully monitored. The recently published results of 20-year follow-up in 2 important studies confirm that BCT achieves equal survival compared to mastectomy in women with early breast cancers, even after all causes of mortality have been considered. The introduction of sentinel lymph node biopsy has further decreased the adverse impact of breast cancer treatment on women. As variation in local control does not affect survival, more efforts are being put into developing adjuvant systemic treatment with curative intent. Adjuvant chemotherapy has been demonstrated to substantially affect the survival of women with early breast cancers. It is now apparent from numerous studies that adjuvant therapy improves survival in all subgroups of women with early breast cancer, although the absolute benefit varies depending on axillary lymph node status, tumor size, and other prognostic factors. This article reviews recent advances in the management of primary breast cancer, including: long term follow-up after BCT; side effects of radiation therapy in BCT; post-mastectomy radiotherapy; sentinel node biopsy; adjuvant hormone therapy; and chemotherapy, including new strategies such as the incorporation of taxanes, dose-dense chemotherapy schedules, and the use of aromatase inhibitors in place of, or in addition to, tamoxifen.