Breast Cancer Setting Priorities for Effectiveness Research (1990) / Chapter Skim
Currently Skimming:
The Knowledge Base for Key Clinical Issues in Breast Cancer
The Knowledge Base for Key Clinical Issues in Breast Cancer
Pages 9-18
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From page 9... ...
One requirement in selecting key patient management topics for effectiveness studies is to understand what unanswered questions remain and whether they are suitable for projects outside the realm of RCTs. Several clinical subjects are briefly reviewed here because they provide the context within which the committeets discussions about those unanswered questions took place.3 They include detection and diagnosis' staging, and options for treatment of specific patient groups (e.g., women with different stages of primary disease or women with recurrent disease)
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can be based on clinical or pathol 4Repeal of the Medicare Catastrophic Coverage Act, which permitted reimbursement for screening mammography for elderly women, eliminated this benefit. The outcome of the relevant legislation was unclear at the time this workshop was conducted, however.
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appears to shrink tumors, relieve symptoms, and prolong survival for some women at these stages. The staging system of breast cancer depends on tumor size and axillary node status as the main prognostic factors.
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Women with Primary Operable Breast Cancer (Stages I and II) Modified radical mastectomy and lumpectomy combined with axillary dissection and radiation therapy are the standard surgical treatment options for Stages I and II disease.5 Four prospective randomized clinical trials SThe terminology used for surgical treatment of breast cancer is important clinically.
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From page 13... ...
include two separate invasive carcinomas in the same breast, diffuse microcalcifications on mammography in the breast containing the cancer, and large tumor masses in small breasts where excision of the tumor would result in an unacceptable cosmetic appearance. Radical mastectomy and extended radical mastectomy have not been demonstrated to have a survival advantage over the less morbid modified radical mastectomy, and they are no longer considered standard therapy.
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If, however, a decision regarding adjuvant chemotherapy in the elderly patient is not going to be based on the histologic status of the axillary nodes, axillary dissection can be forgone. The National Surgical Adjuvant Breast and Bowel Project clinical trials have shown, after eight years of follow-up, that about 90 percent of women treated with lumpectomy and radiation were free of recurrence of cancer in the same breast, as compared with about 60 percent of those treated only with lumpectomy.
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From page 15... ...
Although the treatment of elderly women with breast cancer may be complicated by the presence of other medical conditions, no evidence suggests that they tolerate radiation less well than younger women or have increased complications. Radiotherapy as part of breast conservation may present logistical difficulties to the elderly patient because it requires daily hospital visits for six weeks; such problems should be taken into account but not be a primary consideration in clinical recommendations about therapy.
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From page 16... ...
Accurate staging and other data are crucial in helping to direct patient management decisions and thus are important for valid effectiveness research in this group of patients. Women with Recurrent Breast Carcinoma Although a variety of chemotherapeutic and endocrine regimens can cause tumor regression and symptomatic relief in patients with advanced breast cancer, complete recovery is rarely achievable.
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have a minimal impact on survival. Further information on treatment of microscopic DCIS will be available with the completion of a current randomized clinical trial that is comparing treatment by excision alone and excision plus radiation.
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Both medical and philosophic questions must be thoroughly discussed with the patient. An understanding of patient views and preferences about alternative therapeutic strategies and the attendant impacts on quality of life will be critical to an adequate evaluation of the effectiveness of those therapeutic strategies.
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