Comprehensive management of locally advanced breast cancer.

The definition of locally advanced breast cancer includes patients with large tumors, extensive regional lymph node involvement, or direct involvement of the skin or underlying chest wall. Most of these patients have very poor survival with standard treatment modalities, and over the past 20 years combined modality therapy has been used to improve local and systemic control. There is limited information suggesting that patients with operable locally advanced breast cancer have an improved survival if treated with surgery (or radiation therapy) followed by systemic chemotherapy, as compared with patients treated with local modalities alone. Uncontrolled trials strongly suggest that patients with any stage of locally advanced breast cancer achieve high response rates after induction chemotherapy. Most of these patients can be rendered disease free after combined modality therapy, and their disease-free and overall survival rates appear to be improved when compared with historical controls. These results are most impressive for patients with inflammatory breast cancer, a disease previously found to be uniformly lethal when treated with local modalities of therapy alone. More recently, 30% to 50% of these patients were alive and disease free 5 years after diagnosis, and a substantial percentage were in the same condition 10 years later. Combined modality therapies are the most appropriate approach to patients with locally advanced breast cancer. Much additional research must be done to improve the results of these therapies and maximize the survival of patients with locally advanced breast cancer.