EPIDEMIOLOGY Breast carcinoma is among the most frequent malignant diseases in the world and is the leading cause of premature death among younger women in developed countries. One in seven women in these countries will develop breast cancer in their lifetime. Since 1940, the incidence of breast carcinoma has gradually increased at a rate of approximately 1% per year in Western countries. On the other hand, mortality from breast cancer has declined in countries with organized population-based mammography screening. Breast cancer mortality rates in the
UK have fallen dramatically, in 1989 when 15,625 women died from the disease compared with 12,047 in 2008. Over the same period, breast cancer age-standardised death rates have fallen by 37% from 42 to 26 per 100,000 women (figure1). The age-standardized mortality rate for female breast cancer in all of the constituent countries of the UK increased until the late 1980s and then rapidly fell. Mortality rates have declined in all age
groups since the late 1980s (figure 2). Between 1989 and 2008, the breast cancer mortality rate fell by 44% in women aged 40-49 years; by 44% in women aged 50-64; by 37% in women aged 65-69; by 39% in women aged 15-39; and by 19% in women over 70. Two major reasons have been attributed to this decline: increased use of screening mammography and greater use and improvements of adjuvant therapies such as hormonal and chemotherapeutic agents. New and more efficient therapeutic regimes have led to prolonged survival of patients and improved quality of life. These interventions have considerably increased the number of breast cancer survivors, and a further increase of 31% is expected from 2005 to 2015.
SURGERY Mastectomy for breast cancer was performed at least as early as 548 CE, when it was proposed by the court physician Aetios of Amida to Theodora. It was not until doctors achieved greater understanding of the circulatory system in the 17th century that they could link breast cancer’s spread to the lymph nodes in the armpit. The French surgeon Jean
Louis Petit (1674–1750) and later the Scottish surgeon Benjamin Bell (1749– 1806) were the first to remove the lymph nodes, breast tissue, and underlying chest muscle. Their successful work was carried out by William Stewart Halsted, who started performing mastectomies in 1882. Stewart became known for his Halsted radical mastectomy, a surgical procedure that remained popular up to the 1970’s and was performed on Betty Ford. We have come a long way since the
days of Halsted. Since the advent of the modern era and the radical mastectomy first performed in 1882, great strides have been accomplished over the last century leading to the modified radical mastectomy in the 1970’s and to present day breast conserving surgery. This represents a major departure from Halsted’s principles of the total resection cancer surgery, which was very disfiguring. Prospective randomised clinical trials
in the 1970’s demonstrated no difference in survival between patients treated with modified radical or radical mastectomy. The most influential of the studies refuting the Halsted’s principles was the NSABP-BO4 trial. Published results of modern prospective randomised trials
comparing conservative surgery with radiotherapy and mastectomy have all shown equivalent survival between the two treatment approaches.
SYSTEMIC HORMONAL THERAPY Advances in hormonal therapy have also had a great insight on breast cancer survival. In the 1880’s a few physicians reported significant regression of breast cancer tumours following removal of the ovaries. In 1896, George Beatson performed the first bilateral oophorectomy as a breast cancer treatment. In 1966, the receptors for oestrogen were identified. With this finding, a target to stop growth of breast cancer cells fuelled by oestrogen was explored. A few years later, V. Craig Jordan showed that tamoxifen could prevent breast cancer in rats by binding to the oestrogen receptors. The FDA approved tamoxifen for hormone positive breast cancer in 1977. The Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) overview analysis demonstrated a significant advantage with the addition of tamoxifen for five years to the adjuvant therapy regimen of
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