7. Management of advanced breast cancer.

Approximately half the patients with breast cancer relapse with locally recurrent or metastatic disease. This disease is incurable but can often be controlled, sometimes for many years. Careful clinical evaluation and restaging provides a baseline reference against which response can be judged. Investigations are selected but may include biochemical screens, blood counts, chest X-ray, isotopic bone scan and radiographs of abnormal regions. Selection of systemic treatment is based on three key factors: the extent, pattern and aggressiveness of the disease; hormone sensitivity; and menstrual status. Chemotherapy is used for rapidly progressing visceral disease such as lymphangitis carcinomatosa or hepatic metastases with deranged liver biochemistry where death ensues rapidly unless disease progression can be reversed. With less aggressive disease, treatment is planned around the oestrogen and progesterone status of the tumour. Those with low tumour receptor levels are unlikely to respond to endocrine treatment and chemotherapy should be considered. For patients with steroid receptor-positive tumours, endocrine treatment is used before chemotherapy is needed and consideration of menstrual status can assist in the selection of the precise approach.