Clifford Hudis, M.D.
Chief, Breast Cancer Medicine Service A ociate Attending Physician
Memorial Sloan-Kettering Cancer Cneter
NY, NY, USA
Breast cancer is the most common life-threatening malignancy in many parts of the world but the death rates from it are falling with the wide read adoption of screening and the broadened use of optimal treatments. As treatment evolves, new challenges and choices are presented to the physicia caring for these patients. Several recent developments include the broadened use of sentinel lymph node ma ing and di ection in place of the traditional axillary procedure, the development of improved hormone therapy optio , the evolution of chemotherapy choices, and the availability of entirely new modalities, such as trastuzumab.
Sentinel node ma ing and di ection was initially developed as a method of avoiding complete axillary di ection in the majority of women with uninvolved axillary nodes. In the quest to avoid mi ing potentially positive nodes, enhanced pathology testing was performed routinely on the sentinel nodes. As a co equence, there has been increased detection of micrmetastatic disease but there is inadequate data to guide clinicia as they attempt to judge the risk a ociated with these findings. A provocative retro ective study suggests that microscopic nodal involvement may be significant.
Historically, ovarian ablation and tamoxifen were the standard hormonal therapies for women with metastatic breast cancer and both have been used in the adjuvant setting ase well. Aromatase inhibitors were available but were toxic because of their lack of selectivity. The recent development of selective aromatase inhibitors has allowed clinicia to use this cla of therapy with far le concern for side effects. As a cla , these drugs have been shown to be equal to or better than tamoxifen in post-menopausal women in both the advanced and adjuvant settings. Their optimal use remai undefined.
Combination chemotherapy in the adjuvant setting reduces the risks of rela e and death for patients with invasive breast cancer and adds to the benefits obtained with hormonal treatments. Standard chemotherapy regime have generally included two or more drugs given over a period of 12 to 24 weeks or longer. In general, anthracycline-containing regime are superior to those without these agents, treatments longer than six months are not advantageous, and very high dose-regime - meaning those that require autologous stem cell su ort - have not proven significantly or co istently superior. Agai t this background, the development of the taxanes in the 1990\'s was important because these drugs a eared to be non-cro resistant, had partially non-overla ing toxicities, and were highly active. Hence, many adjuvant therapy trials testing the value of taxanes were developed and are now providing information on their role. To date, nearly every adequately