E

Eczema of the breast: eczema is dermatitis of the skin, characterised by chronic inflammation, of unknown aetiology. This can affect the breast and when sited around the nipple-areolar complex, needs to be distinguished from Paget's disease (see entry). An out-patient biopsy often helps confirm the diagnosis.

Endocrine therapy: (1) Adjuvant endocrine therapy for operable breast cancer is part of standard multidisciplinary management (surgery, chemotherapy, radiotherapy and endocrine therapy). Positive oestrogen and/or progesterone receptor status increases the usefulness or the chances of success of endocrine therapy. The commonest endocrine therapy is tamoxifen, which is a drug that has withstood the test of time (see tamoxifen entry). Tamoxifen reduces the risk of breast cancer spreading to distant sites, reduces the risk of the development of new primary cancers in the same and opposite breast. It has a good response rate in pre-menopausal as well as post-menopausal women. The aromatase inhibiotors are a newer class of drugs that block oestrogen production from ovarian and other natural body sources. Examples are anastrazole (Arimidex), letrozole (Femara and exemestane (Aromasin).  Each of these have been shown to be very effective in breast cancer. Sometimes, the aromatase inhibitors are used instead of tamoxifen for a five year duration. Alternatively, two years of tamoxifen are followed by three years of an aromatase inhibitor. Sometimes, women who have completed five years of tamoxifen are recommended to take letrozole for a further duration, usually another 5 years to give ten years if treatment. Zoladex (goserelin) is an inhibitor of reproductive hormone production, given as a depot injection once a month. Studies have shown a reduction of recurrence risk as adjuvant therapy in addition to tamoxifen in premenopausal women treated for breast cancer. Zoladex may be offered to women who are oestrogen receptor positive in conjunction with tamoxifen who continue to be premenopausal after chemotherapy and tamoxifen. (2) Endocrine therapy can be used for advanced breast cancer (locally advanced - stage III, or distant spread - stage IV), and the tumour response monitored. Multimodality management with either surgical or radiation treatment, or chemotherapy may also be necessary. (3) Primary endocrine therapy may be used in certain clinical circumstances to treat operable breast cancer. In post-menopausal  patients that have oestrogen receptor positive breast cancer, tamoxifen or an aromatase inhibitor may be used as primary therapy to shrink the tumour. Tumours that appear to respond initially may subsequently relapse. Consequently, any intention to avoid surgery may have to be reconsidered when the patient is older. Primary endocrine therapy may be considered in patients in whom operative treatment poses a considerable anaesthetic threat. Breast lumps can be excised under local anaesthetic and is an alternative for at-risk patients with operable breast cancer.  (4) In younger women with borderline indications for adjuvant chemotherapy, a combination of zoladex (one monthly injections for two years) and tamoxifen (for two years with zoladex then three years on its own) may be considered with equivalent outcomes compared with chemotherapy but possible better quality of life outcomes.