MEDICAL MANAGEMENT IN CARCINOMA OF THE BREAST.

Abstract

The medical management of breast cancer actually begins with the first visit of the patient and continues throughout her entire life. It starts with educating the patient to be alert to suspicious signs and to develop a healthy attitude toward the disease when present. It continues with the first suspicion of a pathologic condition as revealed by an adequate history and a painstaking breast examination, the planning of proper diagnostic procedures to establish the diagnosis, the selection of the best available surgeon for definitive therapy and of the best available radiotherapist when the need for radiotherapy is indicated. Then it continues with postoperative follow-up, the decision as to the use of so-called prophylactic ancillary procedures, and finally the management of disseminated cancer which unfortunately occurs in the majority of women who have had breast cancer. I will confine my remarks to certain points that are especially pertinent to what the medical oncologist can contribute to the total care of the patient with breast cancer, as a member of the professional team together with the surgeon, the radiologist, and the pathologist (1). Although time is of the essence when a suspicious area is discovered in the breast, a reasonable search for evidence of metastases should be made before planning radical definitive surgical procedure. This should include not only the usual routine film of the chest but a careful search as well for evidence of distant metastases. Far too often patients are admitted to our disseminated breast cancer clinic with findings of metastases within one or two months after a radical mastectomy, and the history and physical findings suggest that the disease was already disseminated several months before the so-called definitive surgery. If a more complete work-up had been done before the decision to operate, the patient would have avoided unnecessary surgery. One of the commonest questions that arises at the time of radical mastectomy in patients who are premenopausal is whether castration should be done “prophylactically.”3 Adequate information as to the value of this procedure is not yet available. However, a retrospective study by B. J. Kennedy revealed no difference in the total survival between those patients castrated before dissemination of cancer was clinically evident and those castrated for disseminated disease (2). A national randomized study of the value of this procedure is now going on, but it is far too early for any valid conclusions to be made because of the great variability in the interval between the primary disease and the clinical manifestations of dissemination. It seems logical to assume, however, that clinical evidence of metastases might be delayed in about 30 per cent of the menstruants.