RESUMEN

Breast cancer is the leading cause of neoplastic death in women around the world. In the era of personalized medicine, legitimately awaited by our patients, the future of breast cancer screening will depend on an individual-based risk assessment, making it possible to better adapt the age of onset, frequency and the type of examinations useful for this screening. This article reviews the three broad categories of highest risk factors available to establish a risk score appropriate for each patient.

Le cancer du sein est la première cause de mortalité par néoplasie chez la femme de par le monde. À l'ère d'une médecine personnalisée, légitimement attendue par nos patientes, l'avenir du dépistage du cancer du sein passera par une évaluation du risque sur base individuelle, permettant d'adapter, au mieux, l'âge de début ainsi que la fréquence et le type des examens utiles pour ce dépistage. Cet article passe en revue les trois grandes catégories de facteurs de plus haut risque disponibles pour établir un score de risque adapté à chaque patiente.

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We tested, in the Province of Liege, an original approach that tends to individualize mass screening for breast cancer considering breast density and the notion of higher risk. We compared the previous recommendations (January to June 2012) in the age ranges of 40-49 years (n = 1.730) and 70-74 years (n = 286) to the new recommendations (June 2012 - December 2014) in the age ranges of 40-49 years (n = 11.123) and 70-74 years (n = 2.008). With the new recommendations, 38 % of women aged 40 to 49 years will benefit from a biennial invitation to screening due to a mainly greasy nature of their breasts (BI-RADS 1 and 2), while 11 % are classified BI-RADS 3 and 1 % BI-RADS 4 and are invited to perform an ultrasound to increase the screening sensitivity. A complete breast screening is offered to 6 % of women aged 40-49 years in view of a positive family history, and to 0.3 % of women aged 40-49 years and 8 % of women 70-74 years with a higher risk personal history. This individualized approach of mass screening is easily feasible from a practical viewpoint and the detection rate of breast cancers is increased.

Nous avons testé, en Province de Liège, une approche qui tend à individualiser le dépistage de masse du cancer du sein en tenant compte de la densité mammaire et de la notion de plus haut risque. Nous avons comparé les anciennes recommandations (janvier à juin 2012) dans les tranches d'âge de 40-49 ans (n = 1.730) et 70-74 ans (n = 286) et les nouvelles recommandations (juin 2012 - décembre 2014) dans les tranches d'âge de 40-49 ans (n = 11.123) et 70-74 ans (n = 2.008). Selon les nouvelles recommandations, 38 % des femmes de 40 à 49 ans vont bénéficier d'une convocation biennale au dépistage en raison d'une nature principalement graisseuse de leurs seins (BI-RADS 1 et 2), tandis que 11 % sont classées en BI-RADS 3 et 1% en BI-RADS 4 et sont invitées à réaliser une échographie afin d'augmenter la sensibilité du dépistage. Un bilan sénologique complet est proposé à 6 % des femmes de 40-49 ans pour antécédents familiaux, à 0,3 % des femmes de 40-49 ans ainsi qu'à 8 % des femmes de 70-74 ans pour antécédents personnels de haut risque. Cette approche individualisée du dépistage de masse est facilement réalisable d'un point de vue pratique et le taux de détection des cancers mammaires est plus important.

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Publicly organized population breast cancer screening is presently hotly debated. Indeed, population screening is poorly effective, induces harms in a healthy population and is costly. However, stopping all kind of screening of low- and average-risk women would be problematic as about 70% of breast cancers are diagnosed in those subgroups, and maintaining current population screening in high-risk women would be insufficient. We propose herein a review about the advantages and the inconvenience of individualized screening. The latter could be a more efficient strategy. The principles of individualized screening are (a) to start from the age at which the breast cancer risk is equal to that for an average women aged 50 years, (b) to stop when the risk of co-mortality exceeds the risk of breast cancer mortality, (c) to adapt the exams frequency and the imaging modalities to the individual risk and to the breast density, (d) to reassess regularly and individually the screening strategy, and (e) to discuss honestly with each woman in order to help her to decide if she participates or not.

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Many factors determine a woman's risk of breast cancer; some genetic are related to family history, others are based on personal factors such reproductive and medical history. A high-risk woman must benefit of a specific screening regimen including breast examination, mammography, ultrasonography and contrast material-enhanced magnetic resonance. But she can also benefit of chemo prevention or/and risk-reducing surgery such bilateral prophylactic salpingo-oophorectomy and bilateral prophylactic mastectomy.

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Breast cancer incidence in Belgium is on the top of European countries, with 9.697 new cases in 2008 and 106/100.000 women/year. The explanation of this high incidence in our country is probably the accumulation of risk factors (many of them are linked to lifestyle), and the impact of screening and registration of cases. The relative impact of each of theses factors is less clear because we don't have powerful statistical studies. Belgium is slightly above the European mean for breast cancer mortality, with 19,4/100.000 women/year and an all stages 15-year survival of 75%. Breast cancers are responsible for around 3% of all-cause mortality in Belgian women. This article discusses the causes of this high Belgian incidence and of current decrease of incidence in western countries, and reviews known and less known risk factors of breast cancers, with a special focus on menopause hormonal treatments.

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Bilateral prophylactic mastectomy is the most efficient risk management strategy for women at very high risk for breast cancer. Different methods can be used. The implementation of such a strategy must respond to the request of a well informed patient.

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This study reports a consecutive serie of 427 breast neoplasms (411 patients) diagnosed and treated in our department between 1994 and 2004. Patients' records were prospectively collected including personnal medical history and the major elements of the diagnostic and the therapeutic protocol applied. 12 patients (3%) had to be excluded due to incomplete follow-up data. With a median follow-up of 8 years, a 4.5% loco-regional relapse rate is noted while 11% of patients recurred at distant sites and 9% died of their disease progression. These statistics are comparable to those published by prominant breast cancer centers. Amongst the 16% of deaths (67/411 Pts), 54% are due to breast cancer progression. The results are discussed with the aim to upgrade the diagnostic and the therapeutic protocols offered to our patients.

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The status of the axillary lymph nodes is one of the most important prognostic factors in women with early stage breast cancer. Histologic examination of removed lymph nodes is the most accurate method for assessing spread of disease to these nodes. Axillary lymph node dissection (ALND) remains the standard approach for women who have clinically palpable axillary nodes. The benefits of ALND include its impact on disease control (axillary recurrence and survival), its prognostic value, and its role in treatment selection. However, the anatomic disruption caused by ALND may result in lymphedema, nerve injury, and shoulder dysfunction, which compromise functionality and quality of life. For patients who have clinically negative axillary lymph nodes, sentinel lymph node (SLN) biopsy offers a less morbid method to determine if there are positive nodes, in which case axillary node dissection would be necessary. Patients who are SLN-positive should undergo complete ALND. Axillary reverse mapping (ARM) is a recent improvement of ALND which, like the biopsy of the GS, would reduce morbidity.

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Following Beatson's publications in 1896, various modalities of endocrine therapy applied to breast cancer have been developed. Endocrine treatment has greatly contributed to the improvement of the disease's prognosis. Tamoxifen has established itself as a first choice adjuvant therapy for patients with tumors expressing hormone receptors. Over the last decade, third generation aromatase inhibitors have demonstrated their efficacy amongst menopausal patients, alone or in combination with tamoxifen. Efficacy of these medications is dependent on patient's compliance. This article proposes a synthesis of the main knowledges available in the field of breast cancer endocrine therapy.

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The prevention and the treatment of oestrogen deficiency induced by breast cancer treatments are crucial in the management of patients. The impacts of this deficiency must not be neglected: quality of life impairments inducing eventually premature withdrawal of hormonotherapies, and excess of bone and cardio-vascular morbidities and mortalities, especially in good prognosis young women. Management strategies of short and long term effects of this deficiency are reviewed and discussed here.

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The aim of adjuvant hormone therapy for breast cancer is to reach, in daily practice, an efficacy similar to that obtained in clinical trials. In spite of the demonstrated efficacy of hormone therapy, compliance represents a major challenge and a multidimensional problem. A better understanding of the reasons underlying non-compliance would help identify the patients at higher risk and would permit the implementation of strategies to improve compliance to adjuvant hormone therapy. With this in mind, we undertook a review of the recent literature on the topic (Pub Med 2003-2009).

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PURPOSE: Assessment of our experience and validation of the sentinel lymph node biopsy technique in breast cancer stage T0-T2N0M0 surgery. METHODS: Identification and biopsy of the sentinel lymph node by the radio colloid method in a consecutive series of 205 patients undergoing surgery for breast cancer stage T0-T2N0M0 between October 1998 and January 2007, initially in association with a complete axillary lymph node dissection (learning curve), later in an elective way. Prospective recording of the data and analysis with an average follow-up of 50 months (3 to 102 months). RESULTS: Biopsy rate of the sentinel lymph node of 90%, false negative rate of the method 2.5%, axillary recurrence rate 0%. CONCLUSION: We confirm in this series that the sentinel lymph node biopsy technique is a reliable approach in our experience for the evaluation of the axillary lymph node status in breast cancer stage T0-T2N0M0.

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The literature on screening mammography provides ample opportunity for doubt (the sceptics) and dogma (the screening zealots), and can be interpreted to prove both benefit and harm. The benefit of mammography screening, if any, is modest and the balance between beneficial (potentially, a 20% relative reduction in breast cancer mortality with no significant benefit on all-cause mortality) and harmful (physical and psychological morbidity related to the 15-40% missed cancers and the 80-90% false-positive diagnoses) effects is still delicate. The mammogram alone is a modest weapon. Concurrent clinical breast examination is mandatory. Women that are concerned about breast cancer should be fully informed of the potential benefits and risks of screening mammography. These women should benefit from mammography with concurrent clinical breast examination, and possible whole-breast ultrasound in heterogeneously dense and extremely dense breast patterns.

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