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Breast cancer is the leading cancer diagnosis among American women, accounting for nearly one in three cancers in that group (ACS 2006, p. 1). Figure 1 depicts incidence of and death rates from female breast cancer and rates of late-stage breast cancer diagnosis in the United States from 1997 to 2002. Cancer incidence is measured as the number of new cases each year for every 100,000 women while the death rate is measured as the number of deaths each year for every 100,000 women. Overall these figures seem promising; the declining fatalities and increasing five-year survival rates indicate that larger numbers of women survive a cancer diagnosis. However the incidence of female breast cancer has steadily increased since 1980. The increase is largely attributed to more mammography screenings in women ages forty and over. For example, 29 percent of women in the forty and over group were tested in 1987 as compared to 70 percent in 2000. Although the mortality rate declined during the 1990s, rates of late-stage (metastases) breast cancer diagnosis have remained stable since 1980 and hover around 7 per 100,000 women (National Cancer Institute [NCI] 2005a, p.1). Patients diagnosed in later stages are less likely to benefit from treatments or recover as easily as those whose diseases were discovered at earlier stages.

Cancer-related health disparities remain among population subgroups in the United States. Both incidence and death rates generally increase with age--more that 95 percent of new cases occurred in women forty and older. The average age at diagnosis is sixty-one. Caucasian women have the highest incidence of breast cancer (141.1 per 100,000, 1998-2002) but black women have the highest rate of breast cancer death (34.7 per 100,000). Hispanics, Asians, and women of other minority groups have lower incidence of and death from breast cancer (ACS 2006, p. 2). A recent study also confirmed treatment disparities between Caucasian and minority women; minority women with early-stage breast cancer received fewer cycles of cheomotherapy than Caucasian women (Bickell,Wang, Oluwole, et al. 2006).

Early remedies for the cancer were surgical or conservative. Doctors preferred conservative treatment, which included purging, specific diets, bloodletting, and medicines. In the nineteenth century, Viennese surgeon Theodor Billroth confirmed that breast cancer traveled to regional lymph nodes before spreading to other parts of the body. As a result radical mastectomy, also known as Halsted mastectomy, was the major treatment for breast cancer until 1979. The radical mastectomy removes the breast and the underlying muscle in the chest wall or pectoral muscle. In the 1980s modified radical mastectomy became standard, while breast conservation therapy (BCT) was the preferred treatment in the 1990s (Altman 1996, Olson 2002). BCT combines a lumpectomy with radiation therapy. A modified radical mastectomy removes the whole breast, some axillary lymph nodes, and possibly part of chest wall muscle. A lumpectomy removes only the tumor and a rim of normal surrounding breast tissue (NCCN 2005).

Therapies in the early twenty-first century are based on a number of factors, including age, onset of menopause, severity, histologic and nuclear grade of the primary tumor, estrogen-receptor (ER) and progesteronereceptor (PR) status, measures of proliferative capacity, and HER2/neu gene amplification. Patients can choose between standard treatments and clinical trials. Standard treatments include surgery, radiation therapy, chemotherapy, and hormone therapy. Typical surgeries include lumpectomy, partial mastectomy, total mastectomy, modified radical mastectomy, and radical mastectomy. In 1990 the National Institutes of Health (NIH) Consensus Development Panel concluded that BCT provided the same survival rates as women who chose total mastectomy and axillary dissection. Accordingly the NIH recommends BCT for women with early-stage breast cancer (stages I and II). Despite the NIH recommendation, the modified radical mastectomy remains the most common surgical procedure for women diagnosed with early-stage breast cancer (Altman 1996, NCI 2005b). A recent study concluded that more patient involvement in treatment decision making was associated with greater use of mastectomy (Katz, Lantz, Jamz, et al 2005). Concern about disease recurrence was cited as the most influential factor when women chose mastectomies over BCT.

Radiation therapy uses high-energy x-rays or other forms of radiation to destroy cancer cells in the breast, chest wall, or lymph nodes. It is generally used after surgery, especially as part of BCT. The treatment commonly follows a mastectomy in cases with either of the following conditions, a tumor larger than five centimeters in size or positive lymph nodes. There are two different types of radiation therapy: external beam and internal. External beam therapy, which is most common, uses an external machine to deliver the radiation, while a radioactive substance (usually sealed in needles, seeds, wires or catheters) is inserted into the body in or near the tumor in the internal method (NCCN 2005, NCI 2005b).

Chemotherapy and hormone therapy are systemic treatments, meaning they both use drugs to stop the growth of cancer cells. Chemotherapy can be used before surgery (neoadjuvant treatment) and after surgery (adjuvant therapy). The goal for neoadjuvant treatment is to shrink the tumor enough to make surgical removable possible, especially for women who have a large tumor and prefer to undergo BCT. Adjuvant therapy kills cancer cells that break away from the primary tumor and spread through the bloodstream, and do not show up on diagnostic tests such as an X-ray and CT scan or can not be felt during the physical examinations by physicians (NCCN 2005, NCI 2005b). Systemic treatment can be given intravenously or orally and is more effective when combinations of more than one drug are used together. Chemotherapy has been recommended for women with positive lymph nodes since 1985, but younger women are more likely to receive chemotherapy than older women. For example, in 2000, 86 percent of women ages twenty to sixty-four with nodepositive breast cancer received chemotherapy as compared to 45 percent of women sixty-five and up with similar conditions. For women whose breast cancers have spread to other organs in the body (metastases, stage IV), systemic treatment is the main treatment.

For women with estrogen- and progesterone-receptor positive tumors, hormone drugs are given after standard treatment to prevent recurrence. There are two types of hormone drugs, anti-estrogen drugs and aromatase inhibitors. Tamoxifen is the most commonly used of the anti-estrogen drugs, which act to block estrogen after it is produced. It is often prescribed for five years. Aromatase inhibitors, which interfere with the production of estrogen, have the same or better effects, but fewer side effects compared with tamoxifen. Accordingly they are the preferred adjuvant hormone therapy for postmenopausal women (NCCN 2005).

In addition to standard treatments, patients can also participate in clinical trials testing promising treatments. A new treatment is normally studied in three phrases of clinical trials before it is eligible for approval by the Food and Drug Administration (FDA). The last phase involves enrolling thousands of patients with one group receiving the standard treatment and the other group receiving the new treatment. Between 2000 and 2005, a clinical trial tested the effectiveness of trastuzumab (also called Herceptin) on women who have tested positive for the HER2/neu receptor. The study enrolled more than 3,300 patients with early-stage breast cancers and positive axillary lymph nodes and concluded that patients who received trastuzumab combined with standard chemotherapy had a 52 percent decrease in disease recurrence compared to patients treated with standard chemotherapy alone. Because of this finding, trastuzumab has become part of standard chemotherapy treatment for about 20 to 25 percent of breast cancer women whose tumors are HER2/neu receptor positive (NCI 2005c).

References:

Altman, Roberta. 1996. Waking Up, Fighting Back: The Politics of Breast Cancer. Boston: Little, Brown.

American Cancer Society. 2006. Breast Cancer Facts and Figures 2006. Atlanta: American Cancer Society, Inc.

Altman, Roberta. 1996. Waking Up, Fighting Back: The Politics of Breast Cancer. Boston: Little, Brown.

Bickell, Nina A.; Jason J. Wang; Soji Oluwole; et al. 2006. ''Missed Opportunities: Racial Disparities in Adjuvant Breast Cancer Treatment.'' Journal of Clinical Oncology 24(9): 1357-1362.

Katz, Steven J.; Paula M. Lantz; Nancy K. Jamz; et al. 2005. ''Patient Involvement in Surgery Treatment Decisions for Breast Cancer.'' Journal of Clinical Oncology 23(24): 5526-5533.

National Comprehensive Cancer Network. ''Breast Cancer Treatment.'' 2005. www.nccn.org 

National Cancer Institute, NIH, DHHS. 2005a. ''Cancer Trends Progress Report: 2005 Update.'' http://progressreport.cancer.gov/.

National Cancer Institute, NIH, DHHS. 2005b. ''Breast Cancer (PDQ): Treatment. Health Professional Version.'' http://progressreport.cancer.gov/.  

National Cancer Institute, NIH, DHHS. 2005c. ''Herceptin Combined with Chemotherapy Improves Disease-Free Survival for Patients with Early-Stage Breast Cancer.'' www.cancer.gov.

National Cancer Institute, NIH, DHHS. 2006. ''A Snapshot of Breast Cancer.'' www.cancer.gov.

Olson, James S. 2002. Bathsheba's Breast: Women, Cancer & History. Baltimore, MD: The Johns Hopkins University Press.

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