Main controversies in breast cancer

Abstract

In this article, we have reviewed available evidence for diagnosis, treatment, and follow-up in female breast cancer (BC). Into daily clinical practice some controversies are occurred. Especially, in the diagnosis field, despite the fact that the optimal age in which screening mammography should start is a subject of intense controversy, there is a shift toward the beginning at the age of 40 although it is suggested that the net benefit is small for women aged 40 to 49 years. In addition, a promising tool in BC screening seems to be breast tomosynthesis. Other tools such as 3D ultrasound and shear wave elastography (SWE) are full of optimism in BC screening although ultrasonography is not yet a first-line screening method and there is insufficient evidence to recommend the systemic use of the SWE for BC screening. As for breast magnetic resonance imaging (MRI), even if it is useful in BC detection in women who have a strong family history of BC, it is not generally recommended as a screening tool. Moreover, based on the lack of randomized clinical trials showing a benefit of presurgical breast MRI in overall survival, it’s integration into breast surgical operations remains debatable. Interestingly, in contrast to fine needle aspiration, core biopsy has gained popularity in presurgical diagnosis. Furthermore, after conservative surgery in patients with positive sentinel lymph nodes, the recent tendency is the shift from axillary dissection to axillary conserving strategies. While the accuracy of sentinel lymph node after neoadjuvant chemotherapy and second BC surgery remains controversial, more time is needed for evaluation and for determining the optimal interval between the two surgeries. Additionally, in the decision between immediate or delayed breast reconstruction, there is a tendency in the immediate use. In the prevention of BC, the controversial issue between tamoxifen and raloxifene becomes clear with raloxifene be more profitable through the toxicities of tamoxifen. However, the prevention of bone metastasis with bisphosphonates is still conflicting. Last but not least, in the follow-up of BC survivors, mammography, history and physical examination are the means of an early detection of BC recurrence.

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Keywords: Breast cancer; Controversies; Diagnosis; Treatment; Follow-up

Core tip: Taking into consideration the progress in diagnosis and treatment in the female breast cancer, it is inevitable that some controversies will come up in daily clinical practice. The aim of this review is to illustrate some of these conflicting issues and make them less “ambiguous”. Thus, this has been achieved in the issues of mammography, magnetic resonance imaging, fine needle aspiration and core biopsy, axillary dissection, internal mammary node sampling, accelerated partial breast irradiation, the sequence of chemoradiotherapy, negative margin width, while controversial are still remain the themes of tomosynthesis, 3D ultrasound, shear wave elastography, positron emission tomography-computed tomography (PET-CT), CT-scan and bone scintigraphy, hormonotherapy, bisphosphonates and sentinel lymph node biopsy.