Based on breast cancer tumour biology in young women, chemotherapy is mostly necessary for BCP. Cytotoxic. In a study from MD Anderson with IBC patients, For the treatment of localized breast cancer, only monoclonal antibodies for. Med Dosim. Autumn;41(3) doi: /writingrewiewservice.fun Radiation therapy for breast cancer: Literature review. Balaji K(1), Subramanian.
breast cancer literature treatment on review
The study concluded that participation in population-based mammography screening programs in Canada was associated with substantially reduced bc a mortality for women 40—74 years of age. Absolute benefit can be measured as the number needed to invite to screening nni or the number needed to screen nns to prevent 1 death The magnitude of the absolute benefit is influenced by the rr , the duration of follow-up, the underlying mortality risks in the population from which the estimate is derived, and whether the estimate is the nni or the nns.
The nni is based on rct s and is not a measure of who is actually screened, only who is invited to screening. The nni can be estimated from observational studies or rct s, but should not be used because the numbers will be inflated by deaths among women invited to screening who never attended screening The nns is equivalent to the number needed to participate and indicates the actual number needed to be screened or to participate to see a benefit.
It is the more accurate assessment of the benefit of screening and is increasingly being used in the literature. Variable estimates of absolute benefit have been noted in the literature depending on whether the nni , nns , or other model inputs were used.
As Table i shows, the nns estimates from the U. Independent Review and the Cochrane systematic review differed by a factor of almost That difference is attributed to the Cochrane systematic review having used the nni rather than the nns and being based on a less-favourable mortality reduction rr: It is important to use long-term follow-up to estimate the nns. That factor is most evident in the Swedish Two-County Trial, in which it was observed that women had to be screened 2—3 times during a 7-year period to prevent 1 bc a death at 10 years of follow-up; that number declined to women at 29 years of follow-up Other benefits to screening include the reduction in costs associated with treatment.
Treatment for individuals diagnosed at an earlier stage is less invasive and costly, which might reduce patient anxiety and improve prognosis A decreased likelihood of axillary lymph node metastases with screening can also result in fewer axillary lymph node dissections and reduced risk of lymphedema.
Most national screening guidelines suggest that there is value in mammography screening for women in their 40s 10 , 15 , 17 , An informed, personal choice for women in their early 40s is widely supported by the U. Several other North American medical societies recommend screening for women starting at age 40 Table i. The acs recommends annual screening for women 45—54 years of age; women 55 years of age and older should then transition to biennial screening Because the bc a growth rate is faster in premenopausal women, the optimal recommended screening interval for those women is annual In postmenopausal women, although the maximal benefit is achieved with annual screening, the incremental benefit of that approach compared with biennial screening is less marked, and in the relevant age group, most programs recommend biennial screening for maximal cost-effectiveness An often-touted reason not to screen women 40—49 years of age is that most bc as occur in women more than 50 years of age.
Surveillance, Epidemiology, and End Results data No abrupt increase occurs at the age of The incidence of bc a can be further subdivided into 5-year age categories, as the acs has done 10 , with the most marked increase in bc a incidence being seen in the 45—49 age category. Hence, the strong recommendation of the acs to begin screening at 45 years of age Figure 1 , Table i.
Oeffinger et al. Limited studies have evaluated screening mammography for women 40—49 years of age. Many of the rct s were designed to include women 50—69 years of age.
Although the Canadian National Breast Screening Study evaluated women 40—59 years of age 30 , it has been challenged because of poor-quality mammography and because the rct allocations were not blinded, with an excess of advanced bc as allocated to the screening arm The Canadian National Breast Screening Study is an outlier among the 8 rct s for screening mammography; it was the only study to show no bc a mortality reduction from screening mammography.
The U. Age rct reported the effect on bc a mortality of mammographic screening for women 40—49 years of age at From to , , women 39—41 years of age in the Breast Screening Programme of the National Health Service were randomly assigned to either an intervention group that was offered annual screening by mammography or to a control group 1: The overall bc a incidence during the year follow-up was similar in the intervention and control groups.
The authors concluded that their results supported an early reduction in bc a mortality with annual screening in women 40—49 years of age. A false positive is defined as recall for additional testing after an abnormal mammogram, in which further evaluation determines that the initial abnormal finding is not cancer.
False-positive results are one of the most common adverse effects of screening. Most will be resolved with further noninvasive imaging work-up, but a percentage will require further tissue diagnosis for example, a core biopsy , with the findings being mostly benign. False-positive results invariably lead to some level of anxiety for screening participants. The variability in the recall rate is a result of many factors, including use of postmenopausal hormone therapy, greater mammographic density, first mammogram, longer intervals between screens, lack of previous mammograms for comparison 33 , and differences in performance and training of the interpreting radiologists In Canada, data about abnormal recalls from screening programs are publicly available from the Canadian Partnership Against Cancer These quality indicators help to demonstrate the performance and effectiveness of provincial organized screening programs, summarized in Table ii.
Most women who receive an abnormal screening result do not go on to be diagnosed with bc a; however, additional assessment is required to reach a definitive diagnosis. The assessment process can include additional imaging with diagnostic mammographic views, breast ultrasonography, or core or fine-needle aspiration biopsy. Several autopsy studies have demonstrated the frequent presence of breast malignancy in women with no diagnosis before death.
Overdiagnosis can result in unnecessary worry, additional imaging or diagnostic work-up, and overtreatment. To obtain an accurate estimate for overdiagnosis, it is important that the screened and unscreened populations studied have similar risk factors for bc a and that adjustments be made for any confounders. Lead-time bias—the time between detection of the disease as a result of screening and the time at which the diagnosis would normally have been made when the patient presented with symptoms—must be accounted for.
Because of lead time, an excess incidence of bc a is expected when screening starts. After the end of screening, a reduction in the incidence of bc a should occur because of the earlier diagnosis of cancers during screening.
If follow-up is insufficient, then the compensatory drop will overestimate any overdiagnosis. The estimation of overdiagnosis requires accurate correction for changes in the baseline incidence of bc a.
The problem is that the incidence of bc a has changed over time Use of an incorrect assumption about the incidence of bc a could inflate the estimate of the magnitude of overdiagnosis. For example, Bleyer and Welch 41 reported that the incidence of bc a increased by 0. But, 4 years later, Welch et al. Those authors argued that the flat incidence line for metastatic bc a was evidence for massive overdiagnosis from screening mammography. However, if the incidence of bc a had risen steadily, then the flat incidence rate for metastatic bc as was, in reality, evidence of the benefit of screening and a low rate of overdiagnosis.
Surveillance, Epidemiology, and End Results program, attributed to the advent of widespread screening mammography Puliti and colleagues undertook a literature review of observational studies to estimate a range for overdiagnosis of bc a, including carcinoma in situ, in 7 mammographic screening programs in Western Europe Studies were critically reviewed for the methods used to estimate counterfactual rates what would have happened without screening and to adjust for lead-time bias.
The thirteen studies that satisfied the eligibility criteria reported 16 estimates of overdiagnosis. The overtreatment that accompanies overdetection is what causes the harm. Most overdetection is driven by the diagnosis of ductal carcinoma in situ dcis. The literature contains much debate about the value of screen detection of dcis and subsequent treatment of the disease.
Before the widespread use of screening mammography in the United States, 6 cases of dcis were detected annually per , women; after the introduction of screening, 37 cases of dcis were detected per , women On mammography, dcis is most often detected as new microcalcifications Figure 2 , although it can present as a palpable mass.
It can also be both mammographically and clinically occult. Breast magnetic resonance imaging mri has been shown to be more sensitive than mammography for detecting high nuclear grade dcis The main goal of bc a screening is to detect bc a early and thus to lower the incidence of locally advanced bc a.
A Bilateral digital mammograms demonstrate heterogeneously dense breasts American College of Radiology, BI-RADS C , with a large spiculated mass in the central left breast causing left nipple retraction corresponding to the palpable mass. An ultrasound-guided breast biopsy not shown confirmed invasive ductal carcinoma, with axillary node metastases. B Maximal-intensity projection image from magnetic resonance imaging shows tumour occupying most of the left breast, measuring more than 5 cm.
C Photographic enlargement of the left breast mass shows fine pleomorphic calcifications within the mass, characteristic for DCIS. D Photographic enlargement of the left breast from a screening mammogram 2 years earlier shows a smaller cluster of calcifications within the same area, not detected at screening. E Photographic enlargement of the left breast from a screening mammogram 5 years earlier shows a very small group of fine pleomorphic calcifications, likely DCIS, identified only in retrospect.
Does detecting dcis reduce the rate of invasive cancer? Currently, no tools are available to predict which dcis will progress and which will not.
In the United Kingdom, Duffy et al. Data were obtained for 5. Interval cancers diagnosed symptomatically within 36 months after the relevant screen were recorded. The average detection frequency of dcis was 1. A significant negative association was observed for screen-detected dcis and the rate of invasive interval cancers; for every 3 screen-detected cases of dcis , 1 fewer invasive interval cancer occurred in the subsequent 3 years.
The study concluded that detection and treatment of dcis was worthwhile for the prevention of future invasive disease. To mitigate the harm of overdiagnosis, women should be involved in the decision-making for dcis treatment, based on information about the risks of treatment compared with watchful waiting.
False negatives are more likely with certain bc as—in particular, lobular carcinomas that tend to grow along the normal breast architecture in a lepidic pattern, making them more difficult to detect. False negatives are also more likely in patients with dense breast tissue, which masks bc a. One technologic advance in screening mammography was the transition from film screen to digital mammography.
The dmist trial showed that, in women with dense breasts, the sensitivity of digital mammography was significantly increased Increasingly, dbt is being used as an adjunct screening tool for the detection of bc a. Two-dimensional 2D mammography and tomosynthesis can be obtained in a single compression, and synthesized 2D projection images can also be reconstructed from the dbt data The radiation dose received when dbt is combined with conventional 2D mammography is nearly double that of digital mammography alone, but within the established and acceptable safe dose limits 53 — When combined with digital mammography, dbt helps to improve bc a screening and diagnosis.
Several screening studies have shown incremental invasive cancer detection rates of 1. The main advantage of tomosynthesis is its ability to diminish the masking effect of tissue overlap and structure noise usually encountered with 2D mammography. If dbt is used in the screening setting, the marginal definition is equal to that of spot magnification, and so women with masses detected at screening can forego additional mammographic views and attend just for ultrasonography. Few studies have investigated the long-term sustainability of the improved screening outcomes with dbt.
A retrospective analysis looked at outcomes data from 3 years of dbt screening of an entire population at an academic centre. The results showed that dbt screening outcomes were sustainable, with a significant recall reduction, an increase in the cancer cases identified in recalled patients, and a decline in interval cancers The tmist trial is the first large randomized multicentric study to assess whether, compared with conventional mammography alone, dbt combined with digital mammography is more effective at lowering the incidence of advanced bc as see NCT at http: In the United States and Canada, , asymptomatic women between the ages of 45 and 74 years will be enrolled.
The study aims to provide a modern basis for implementation of the combination technology for bc a screening. The Canadian Lead-in Study began recruitment in , and the full study opened in Currently, no widely accepted view for the supplemental screening of women with dense breasts has been reached, even though the sensitivity of screening mammography is recognized to be reduced in such women.
No rct s have determined any mortality benefit from supplemental screening. Multiple studies have shown increased detection 3—4 per of small, invasive, node-negative cancers when supplementary screening is performed for women with dense breasts 72 , The j-start prospective rct of ultrasonography has shown favourable preliminary results for detecting early-stage cancers, with fewer interval cancers Currently, 32 U.
Personalized screening could become more of a reality in the future, whereby, depending on risk and density, supplemental screening might be offered.
That approach has been proposed in Quebec with the international Perspective Project Recently, studies of contrast-enhanced mammography have shown promise in improving the detection of bc a by relying on its enhanced vascularity 76 , Although still experimental and currently used only in the diagnostic setting, that type of screening could have future applications.
Breast mri has also recently been proposed as a method of screening for average-risk women: In the latter study, more biologically active tumours were found with mri. However, given the higher cost, the requirement for intravenous contrast, and the lower specificity, breast mri has not become a part of routine screening.
For women who undergo biopsy, only 1 in 3 will be diagnosed with a malignancy. False negatives with mammography are an important limitation, often being related to bc as hidden by dense breast tissue. Digital breast tomosynthesis has the potential to simultaneously increase cancer detection and lower the rate of false positives.
In addition, supplemental screening with breast ultrasonography, breast mri , and contrast-enhanced mammography shows promise for further increasing the detection of biologically significant bc as in women at higher risk of bc a. In , based on the best available current evidence, screening mammography should be recommended every 1—2 years for women 40—74 years of age at average risk.
In future, as assessment of risk and breast tissue density becomes a reality, more personalized screening will likely be added to that screening mammography regimen. Cancer incidence and mortality worldwide: Int J Cancer ; Estimates of global cancer prevalence for 27 sites in the adult population in Estimates of the worldwide mortality from 25 cancers in Canadian Cancer Statistics Toronto, ON: Canadian Cancer Society; The benefits and harms of breast cancer screening: Lancet ; Effectiveness of screening with annual magnetic resonance imaging and mammography: For instance, therapeutic strategies may be associated with similar survival but different toxic effects; alternatively, one therapy may yield better survival but more severe side effects, while another may offer poorer survival but better quality of life QOL during the patient's remaining months or years.
Thus, decisions about alternative therapies are often based on QOL considerations, in addition to the likelihood of survival 1 , 2. Even when cures are possible, the costs of treatment may exceed an individual's or society's willingness to pay. Although QOL has been an implied medical outcome since the time of Hippocrates 3 , 4 , the landmark paper by Karnofsky et al. The next major tools developed to assess the impact of cancer and breast cancer therapy on QOL were not developed until the early s.
Increasing consumerism and patient participation in health care decisions, occurring in parallel with the growth in interest in outcomes of care in the late s and the s, set the stage for the development of patient-based measures of general and breast cancer-related QOL 4 , 7. For example, in , Ware et al. Preliminary incorporation of such measures into cancer cooperative group randomized controlled trials RCTs occurred in the late s 4 , 9.
Despite the recent explosion of QOL measures, particularly for breast cancer, routine incorporation of QOL outcomes into cancer research has been slow, and when used, outcomes have often been poorly measured. Thus, there is a clear need for expanded research on practice-based outcomes measures. For such measures to be clinically relevant and feasible to collect, it is key that the research and clinical communities work together to take an active leadership role in this process.
To set the stage for such activities, we review the current use of health outcomes across the spectrum of breast cancer care—from primary prevention and early detection through survivorship or death—that could be used as the basis of a research agenda for measuring the outcomes of breast cancer care. This review is intended to serve as a focal point for discussion and extension of existing efforts to improve the outcomes of breast cancer services. We conducted a qualitative review of the literature on breast cancer health outcomes across all phases of breast cancer care, including primary prevention, early detection, diagnosis, local treatment, adjuvant treatment, treatment of metastatic disease, survivorship, and the dying experience Outcomes research is the study of the net effects of the health care process on the health and well-being of individuals and populations.
As such, it can encompass a wide breadth of issues, including research on satisfaction with care, effectiveness, costs of care, and measurement of patient preferences and QOL. The current construct of QOL draws on earlier use of social indicators, such as housing and employment status, to measure the well-being of populations 12 - Both of these latter definitions reflect the importance of the individual's subjective experience; the second definition highlights the role of personal values, or preferences, for health outcomes 3.
The current consensus among outcomes researchers is that QOL is a multidimensional concept 3 , 18 - Although there is variation in the number and types of HRQOL domains suggested by different researchers, there is substantial overlap. Most researchers would agree that the following domains should be considered when deciding on HRQOL measures: The precise number and types of domains should be sufficiently broad to capture the impact of the illness or treatment on the patient but not to impose an undue burden on the patient or researcher; if the impact is largely unknown, the largest number of dimensions should be included while maintaining parsimony.
Any one domain may be an outcome in and of itself. A National Cancer Institute-sponsored workshop on the measurement of QOL in cancer clinical trials 22 recommended that assessment be multidimensional, include general and cancer-specific tools, be patient self-reported, be measured at more than one point in time, and be evaluated after controlling for relevant medical and sociodemographic characteristics.
These considerations guided our data abstraction. For the purposes of this review, health outcomes were defined as HRQOL or any of its domains, preferences for outcomes, satisfaction with health care or treatment decisions, and economic outcomes, such as costs of care, cost-effectiveness analysis CEA , decision analysis, and cost-benefit analysis.
Multiple sources were used to identify all potential research for inclusion in the analysis. The earlier date of was selected to include research that was representative of current health outcomes and QOL research methods.
The following key words were used for the search: To limit our search more narrowly to QOL, satisfaction with health care or treatment decisions, or economic outcomes, our search of Quality of Health Care and Delivery of Health Care was restricted to articles listing these key words as a major MeSH term.
For the other key words, we selected articles using these terms as major or minor MeSH headings. Because this search did not identify any articles on outcomes associated with the dying experience of breast cancer patients other than survival , we conducted a supplemental search on this topic using the following terms: Study inclusion criteria consisted of being conducted in the United States and Western Europe, being published in a peer-reviewed journal, and presenting data on a health outcome.
If outcomes data, or data subsets, had been published in more than one journal or time period, the largest dataset that contained the highest quality of information was selected for abstraction, although all of the measures were noted.
The full listing of articles retrieved by the search is available from the authors. For studies eligible for inclusion, the following data were abstracted: Data were summarized by use of descriptive statistics, Student's t tests for differences in means, analysis of variance for differences in groups, and chi-square tests for differences in proportions and trends over time.
These articles reported on distinct study samples. In the study period, there was a general increase in the number of articles that included breast cancer outcomes Fig. This increase was largely due to increases in studies of QOL in the treatment and survivorship phases of care and economic studies of screening. Characteristics of studies on the outcomes of primary prevention: Time trends in numbers of breast cancer outcomes research articles: The proportion of these different types of outcomes varied across phase of care, with studies of survivorship having the greatest proportion of outcomes focused on QOL These findings are likely to be due to the nature of screening and diagnosis where the QOL outcomes are short term and difficult to capture, whereas the economic impact of differing strategies on survival may be large.
We did not identify any studies about the quality of the dying experience for breast cancer patients per se. Within the metastatic treatment phase, there were 10 studies about palliative care that met our inclusion criteria 52 - 61 ; most were cross-sectional in design. One study measured outcomes of the patients' caregivers Among the noneconomic studies, slightly more than one half Five studies 69 , 87 - 90 noted use of translation of outcomes assessments into another language or languages.
Few studies [e. There was a wide variety of instruments used in the study sample Table 3 94 - Among the noneconomic studies, There were validated tools represented in the 75 studies that used one or more validated measures. The average number of instruments used per noneconomic study was 2. Studies about survivorship or local therapy had the highest average number of measures per study 3.
With the exception of the studies of chemotherapy-induced nausea and vomiting-prevention interventions, all QOL studies included more than one domain of QOL. Characteristics of studies on the outcomes of screening: Characteristics of studies on the outcomes of diagnosis: Characteristics of studies on the short-term outcomes of local treatment: Characteristics of studies of treatment of metastatic disease: Characteristics of studies on the outcomes of breast cancer survivors: Among the 91 economic studies, only one met current standards for a good quality analysis e.
In terms of power, only 21 studies 63 , 69 , 90 , 96 , - presented information on their power to detect clinically meaningful differences in noneconomic outcomes. Comorbidity is an important covariate that has the potential to confound outcomes results.
However, comorbidity was only specifically measured in four studies—one CEA 76 , two cross-sectional studies of breast cancer survivors 65 , , and one cross-sectional study of newly diagnosed breast cancer patients However, results were not clearly controlled for this potential confounder in the cross-sectional studies.
In longitudinal follow-up studies, baseline QOL can be controlled for in analyses of outcomes. Additional sources of bias in interpreting existing outcomes research include low response rates. In the metastatic disease phase, there is the further challenge of poor response rates or losses to follow-up because of severe illness or death; use of proxy respondents was not addressed in any of these studies.
Finally, none of the studies evaluated whether floor or ceiling effects limited their ability to detect differences in outcome or evaluated the amount of missing data and their impact on results. At present, outcomes measurement is variable in its approach and application to the spectrum of breast cancer care. Although the past decade has witnessed a dramatic increase in the volume of research on breast health outcomes, large gaps exist in certain phases of care, types of outcomes, populations, and standards of measurement.
For instance, only one study evaluated the quality of the dying experience for breast cancer patients, only Only one half of the studies were controlled, and studies of survivors were the least likely to include a controlled design that accounted for baseline differences in health and functioning and other important covariates. At present, the overwhelming majority of research focuses on white, nonelderly populations.
In terms of the quality of the research, this overview highlights certain cross-cutting deficiencies—no studies commented on the potential for floor or ceiling effects to influence results, only one CEA would be considered to be adequate by current standards, and, among the noneconomic studies, only four measured comorbidity, 37 tested reliability in their own patient population, and 21 noted whether they had sufficient power to detect clinically meaningful differences in outcome.
These types of limitations have been noted in other reviews as well Thus, we recommend that a common set of standards be established for the design and conduct of outcomes studies Table 5 , including development of standard, practical tools to measure the burden of illness including the number of illnesses, severity, and impact on function.
Given the complexity of breast cancer care and the heterogeneity in patient populations, no one instrument is sufficiently comprehensive, is sensitive to clinically meaningful changes in outcomes across all phases of care, and has acceptable respondent and provider burden.
Other issues, such as standardizing the optimal timing of measurement within and across phases, were beyond the scope of this review and are important to address in future research. Finally, it will be important to examine whether conclusions about outcomes are affected by choice of instrument. Our review also highlights the paucity of patient preference data. We suggest that additional research be conducted to develop practical methods to measure patient preferences and that these measures be transportable into economic analyses that calculate cost per quality-adjusted life-year gained.
More work is also necessary to understand the quality of the dying experience from both the patient's and the caregiver's perspectives. In summary, more research is needed to develop standard approaches that are 1 practical in a variety of health care settings, 2 reliable and valid, 3 applicable to broad age and race groups and culturally diverse populations, 4 useful to track changes in outcomes as individuals move through the phases of cancer care, and 5 informative for designing interventions to improve the quality of breast cancer services across the entire spectrum of care.
Partnerships to facilitate translation of outcomes research from research centers to diverse community practices will be essential for reaching these goals. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.
Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article navigation. Volume Article Contents. M ethods. R esults. D iscussion. Mandelblatt, C. Armetta, W. Correspondence to: Jeanne Mandelblatt, M. Oxford Academic. Google Scholar. Catherine Armetta. Robin Yabroff. Wenchi Liang. William Lawrence.
Split View Views. Cite Citation. Permissions Icon Permissions. Abstract Background: Appendix Table 1. Author, y reference No. Lerman et al. View Large. View large Download slide. Table 1. Total adds to more than articles because some studies assessed more than one phase of care. Table 2. Table 3. Table 4. Instruments most commonly used in breast cancer outcomes studies: Appendix Table 2.
Haiart et al. Appendix Table 3. Kennedy et al,. Appendix Table 4. Verhoef et al. Appendix Table 5. Berglund et al. RT plus tamoxifen vs. CMF or postmenopausal women receiving tamoxifen vs.
Appendix Table 6. Biermann et al. Appendix Table 7. Marks et al. Table 5. Selection of candidate instruments should be guided by consideration of patient burden and acceptability, feasibility in nonresearch settings, absence of floor or ceiling effects, applicability to multicultural groups, and sensitivity to change over time. Include comorbidity as a covariate in outcomes research; consider interactions of cancer and comorbidity in assessing outcomes.
Begin to include family and caregiver outcomes. Any new survivor studies should be carefully controlled. Outcomes measuring the quality of the dying experience need to be developed, validated, and applied to breast cancer populations. Mandelblatt, W. Liang, and W. Mandelblatt and K. Yabroff and TCA K. We acknowledge the critical reviews of earlier versions of the manuscript by Drs.
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Male breast cancer: a review of literature
We conducted a qualitative review of the literature on breast cancer health outcomes across all phases of breast cancer care, including primary. LITERATURE REVIEW. Breast Cancer .. Breast Cancer treatment and survival Surgical treatment for breast cancer has to do with breast-conserving. Literature Review – Breast Cancer by. Cheryl M. .. Effective means of treating breast cancer are widely available and may be used alone or in combination.