From The Editor's Desk

Robert Perrillo

Breast cancer is an exceedingly common disorder. It is estimated that 180,000 new cases will be detected this year in the U.S. alone resulting in 45,000 deaths. Despite these disturbing statistics, it should also be recognized that rapid advances have been made in the past 10 years with respect to diagnosis, public awareness, treatment, and basic science understanding of disease pathogenesis. Thus, we have chosen to dedicate the first issue of volume 2 of The Ochsner Journal to the recent advances made with this disorder.

As in past issues, we have attempted to approach the focused area from several directions. First, we begin with an historical perspective by Patrick Borgen, Chief of Breast Service of the world-renowned Memorial Sloan-Kettering Cancer Center. Dr. Borgen's article traces the progress in our understanding of this malignancy from the concept that it was the result of an infection whose spread was hastened by surgery, to a disorder that may, at a more basic level, represent a failure of genetic control over tumor-promoting oncogenes. The refinements in surgical and radiotherapy techniques described in Dr. Borgen's article and elsewhere in this issue give encouragement that mastectomy and axillary dissection will become a progressively less common way of dealing with this form of cancer.

Dr. Borgen's review is followed by an article by Drs. Kardinal and Cole of the Section on Hematology and Oncology on the possibility of the prevention of breast cancer in high-risk patients using chemotherapy. The authors report the findings of a 5-year landmark study in which tamoxifen was clearly proven to diminish the rate of invasive as well as noninvasive breast cancer. Furthermore, the encouraging data observed with raloxifene, a drug which was initially studied for osteoporosis, has led to the development of a large clinical trial employing both agents to prevent breast carcinoma in high-risk postmenopausal women. We are proud that Ochsner has been selected as an investigative site for this study.

The results with radiation therapy as an adjunct to surgery are described by Dr. Robert Kuske, Chairman of the Department of Radiation Oncology. As the reader will see, the shift to a greater usage of radiotherapy, which is based upon improved survival in certain subsets of patients and refinements in the means of delivery, is truly an example of a pendulum swing in medicine. His article is, therefore, aptly subtitled “Back to the Future.”

Dr. George Fuhrman and his colleagues of the Department of Surgery present the experience with the first 100 patients to have undergone sentinel node mapping at Ochsner. This promising technique is based upon the premise that if the initial draining lymph node is cancer-free, then the other nodes are likely to be as well, thus avoiding broad axillary dissection. Although the technique is still undergoing refinements, the early data look extremely promising.

Following Dr. Fuhrman's article, Dr. Cole presents data on newer chemotherapeutic agents to treat breast cancer. The review describes multiple approaches to the medical management of breast cancer including taxanes, high-dose chemotherapy with stem cell rescue, monoclonal antibody to a tumor-related transmembrane protein, and newer hormonal agents. Different mechanisms of action make it theoretically possible to employ combinations of agents in the future that have additive or synergistic effects.

The review on chemotherapy is then followed by an article by Drs. Champaign and Cederbom of the Department of Radiology on the value of screening mammography. X-ray screening mammography remains the most sensitive noninvasive technique for detecting early tumors when women are asymptomatic and cancers may still be noninvasive. Ochsner currently has in place a device called the ImageChecker, which is currently the only FDA approved computer-aided detection system; it is anticipated that the improved resolution provided by this device will diminish the 10% to 15% miss rate of conventional mammography.

Dr. Andrew Mason, Associate Editor of The Ochsner Journal, discusses the clues and lines of evidence that point to a viral etiology for breast cancer. This is a highly controversial area, but further scientific studies may ultimately prove a viral etiology for some cases, and, as such, this raises the prospect of vaccination against breast cancer. This would represent as much of a milestone as vaccination of hepatitis B to prevent hepatoma!

Finally, we end this issue with a discussion of the psychological and emotional impact that a diagnosis of breast cancer has on patients as seen from a nurse's perspective. As Alexia Waring points out, an informed patient who takes part in medical decisions is often in a better position to deal with the devastating emotional and psychological consequences following a diagnosis of breast cancer.

We welcome the new millennium with a slightly new look to The Ochsner Journal. As in the past, however, we will continue to focus on areas that have broad importance to practicing physicians. An issue dedicated to minimally invasive surgery is planned for July. As always, we welcome your comments and suggestions and encourage you to contact us with your thoughts on this or any other topic relevant to today's practicing physician.