Combined modality trials in early breast cancer have been underway since the 1960s and results are available to indicate varying degrees of success in Stage I and 11. The trials have involved more than 29,000 women in 61 randomized trials. The recommendations can be summarized by stage, estrogen receptor (ER) status, and menopausal status. In Stage I1 patients, chemotherapy has an impact on disease mortality for ER-positive and ER-negative premenopausal women and possibly ERnegative postmenopausal patients. In postmenopausal Stage I1 ER-positive patients, tamoxifen given for more than 2 years has a beneficial effect on survival. In nodenegative patients, the major effects have been on improving disease-free survival (DFS) rather than overall survival. Tamoxifen has a positive effect in ER-positive patients while chemotherapy benefits ER-negative patients. In at least one trial chemotherapy benefitted women with ER-positive tumors, both premenopausal and postmenopausal, with lesions larger than 3.0 cm. Ongoing trials are designed to answer questions regarding optimal therapy for varying subsets including those tumors in which ER cannot be measured. New prognostic features used to determine therapy include flow cytometry studies of DNA synthesis and oncogene expression. Cancer 66:1378-1386,1990.
N 1980, IN THE STATE O f Wisconsin, about half Of all
I breast cancers were reported as operable at the time of diagnosis, or as limited to the breast. By 1987, almost two thirds of all cancers detected were limited to the breast, a relative increase of about 20%. At the same time, the proportion of patients presenting as having distant spread decreased from 10% to 6%. Thus, breast cancer is being diagnosed earlier. ' From 1968' From to 1972, the 5-year ageadjusted mortality in Wisconsin was 30.2 per 100,000 women, declining to 28.5 by the period from 1983 to 1987. Recent data suggest that the decline in mortality rate may not have continued. As this improvement in earlier diagnosis has occurred, the primary therapy of breast cancer has paradoxically become less dependant on surgery alone and integrated more with radiotherapy and chemotherapy. In other words, more and more