The most recent randomized trials assessing the
impact of more modern radiotherapy regimens
(where efforts were made to limit cardiac exposure)
have demonstrated that locoregional irradiation
(irrespective of the use of cytotoxic or endocrine
systemic therapy) reduces mortality to a similar
degree when compared with adjuvant cytotoxic
chemotherapy, with no discernible increase in cardiac
Conclusions
Breast cancer is a complex disease with great
between-patient variability in its propensity to recur
locally or systemically. The ‘systemic’ paradigm
implies a rigid distinction between these types of
recurrence and is not consistent with the results of
recent trials or biologically plausible. There is a
danger that a belief in ‘biological predeterminism’
could undermine the efforts of surgeons and oncol-
ogists as they strive to reduce the risk of locoregional
recurrence.
There is good evidence that effective multidisci-
plinary management with careful surgical and radio-
therapeutic techniques can minimize long-term
locoregional recurrence. Efforts to prevent local
failure in breast cancer are justified, not only to
avoid the profound trauma of recurrence and the need
for unpleasant salvage treatment, but also to reduce
mortality.
The Use of Tamoxifen in Elderly
Patients
Given the widespread acceptance of surgical excision
as the primary treatment for breast cancer and the
historical context of clinical practice being dominated
by surgery over many decades, there have been few
opportunities to examine the impact of surgery on
mortality within randomized trials.
One such opportunity is presented by the trials of
tamoxifen in elderly patients. The supposition that
tamoxifen alone was sufficient treatment for this
group was tested in two randomized trials. The (UK)
Cancer Research Campaign and (Italian) GRETA
groups randomized 913 patients (median age 76
years) with operable breast cancer to receive
tamoxifen alone or with surgery.
The challenges for clinical research in the
locoregional therapy of breast cancer over the next
10 years are to optimize local control and survival,
provide adequate prognostic information to guide the
use of systemic adjuvant therapy, and minimize
treatment-related morbidity.
References
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overview of the randomized trials.
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The Benefits of Screening
The effectiveness of population-based mammo-
graphic screening is still questioned, despite its
widespread acceptance as public health policy in
many countries. Nevertheless, its legitimacy derives
from several randomized trials that indicate that
screening for women aged over 50 years reduces
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Breast Cancer: Locoregional Control and Survival 173