Curative Treatment

Introduction
Treatment may be curative or palliative. Curative treatment is advised for clinical stage I, II, and III disease (Table 17-2). Patients with locally advanced (T3, T4) and even inflammatory tumors may be cured with multimodality therapy, but in most palliation is all that can be expected. Palliative treatment is appropriate for all patients with stage IV disease and for previously treated patients who develop distant metastases or who have unresectable local cancers.

The growth potential of tumors and host resistance factors vary widely from patient to patient and may be altered during the course of the disease. The doubling time of breast cancer cells ranges from several weeks in a rapidly growing lesion to a year in a slowly growing one. Assuming that the rate of doubling is constant and that the neoplasm originates in one cell, a carcinoma with a doubling time of 100 days may not reach clinically detectable size (1 cm) for about 8 years. Rapidly growing cancers have a much shorter preclinical course and a greater tendency to metastasize by the time a breast mass is discovered.

The long preclinical growth phase and the tendency of breast cancers to metastasize have led clinicians to believe that most breast cancer is a systemic disease at the time of diagnosis. Although it may be true that breast cancer cells are released from the tumor prior to diagnosis, variations in the host-tumor relationship prohibit the growth of disseminated disease in many patients. Clearly, not all breast cancer is systemic at the time of diagnosis. For this reason, a pessimistic attitude concerning the management of breast cancer is unwarranted. Most patients can be cured.

Controversy surrounds the timing of surgery with respect to the menstrual cycle. Some suggest that operation during the time of unopposed estrogen adversely affects survival, but most studies support no such effect. Several randomized trials are currently examining this question.

Choice of Primary Therapy
The extent of disease and its biologic aggressiveness are the principal determinants of the outcome of primary therapy. Clinical and pathologic staging help in assessing extent of disease (Table 17-2), but each is to some extent imprecise. Other factors, such as DNA flow cytometry, tumor grade, hormone receptor assays, and oncogene amplification, may be of prognostic value but are not important in determining the type of local therapy.

Controversy surrounds the choice of primary therapy of stage I, II, and III breast carcinoma. A number of states require physicians to inform patients of alternative treatment methods in the management of breast cancer. Currently, the standard of care for stage I, stage II, and most stage III cancer is surgical resection.