Bisphosphonates offer a potentially effective adjuvant therapy to reduce recurrence of bone metastases in breast cancer patients. Clinical trials are at the early stage, but initial results have shown promise. There are three published adjuvant trials of oral clodronate, and one trial each of pamidronate and zoledronic acid. Observed complications so far include osteonecrosis of the jaw or maxilla because bisphosphonates inhibit bone turnover, as well as renal toxicity. Thus, care needs to be taken with dosage and duration of treatment and patients carefully managed.

Radiotherapy is an important component in the treatment of breast cancer. However, the individual tumor response to radiation is variable, reflecting both the intrinsic properties of the tumor and its microenvironment as well as the different, inherited sensitivity of the patient's normal tissue when exposed to the effect of ionizing radiation. These differences have inspired research to discover the underlying signal transduction pathways and to understand when they pertain to the tumor, the host or both. In fact, understanding the mechanisms underlying radiosensitivity of breast cancer not only does it permit to design more effective radiation treatments, but it sheds light on the complexities of tumor-host interactions in this disease.

Surgical management of breast carcinoma has evolved to include more breast conserving techniques such as skin-, nipple-, and areola-sparing mastectomies, as improved cosmesis becomes an increasing concern. However, the oncologic risk of these procedures must be strongly considered before such techniques can be widely adopted. Here we review available literature on these techniques and their associated clinical outcome. From our own experience, as well as from that reported, we conclude that nipple-, skin-, and areola-sparing mastectomies in carefully selected patients can have safe oncologic outcomes comparable to more traditional surgical techniques and therefore may be a feasible option for breast cancer management.

Benign radial scars, lesions characterised histologically by a fibroelastic core surrounded by stellate duct proliferation, cannot be differentiated from lesions with associated invasive or non-invasive carcinoma on imaging, and histological sampling is therefore mandatory. There is also extensive evidence of the frequency with which radial scars are associated with malignancy and with other lesions that have an associated risk of malignancy. The traditionally accepted management has been the surgical excision of all suspected radial scars because insufficient tissue was removed by standard biopsy techniques to exclude associated lesions. In more recent series, it has been shown that with extensive tissue sampling of such lesions with core biopsy and modern vacuum-assisted sampling devices, the presence of associated malignancy can be excluded, thus negating the need for surgical excision.

Many older women today with early-stage breast cancer have estimated survivals exceeding 5–10 years at the time of diagnosis and should be considered for systemic adjuvant chemotherapy. When available and if eligible, such patients should be offered clinical trials participation. Given the median age for onset of breast cancer, trials should also be developed to specifically investigate the disease in this age group. Oncologists caring for elders need to educate their colleagues as well as their patients concerning the pitfalls of age bias and the potential hazard of under-treatment and poorer outcomes.

Sentinel lymph node biopsy (SLNB) has been adopted as an applicable alternative to the standard axillary lymph node dissection (ALND) level I and II. It makes possible a less extensive axillary surgery in patients with early breast cancer with negative lymph node, who would not benefit from further dissection, in order to prevent unnecessary morbidity. On the other hand, SLNB is not appropriate in every clinical circumstance. In some clinical situations like tumor size T1 and T2, SLNB is, meanwhile, regarded as a standard procedure. In other settings like increased age and body mass index, pregnancy, ductal carcinoma in situ (DCIS), neoadjuvant chemotherapy, advanced disease (T3 and T4), prior surgery and multifocal/multicentric disease, there is a controversial debate about the importance of SLNB. This article reviews the absolute and relative contraindications of this procedure in respect to the latter three clinical situations.

For the advanced breast cancers T3 and T4, there seems to be an increasing evidence of an acceptable accuracy, although it should be further evaluated in randomized clinical trials (RCT). The indication of SLNB in previously operated patients depends on the type of prior surgery. A diagnostic biopsy does not represent a contraindication, whereas the sentinel node biopsy should not be used after an extensive breast surgery neither in the context of oncologic nor non-oncologic purposes. In the context of multicentric disease, there is growing evidence that SLNB is suitable, but actually it should be restricted to RCT. However, the multifocal disease is only a relative contraindication, that is it could be applied in well-selected patients.

Breast cancer and its treatments can cause sexual dysfunction in up to 90% of women with the disease. Front line care providers often do not have the time or training to focus on this quality of life issue and the private nature of the topic can prevent women from pursuing help. By setting up a clinic specifically devoted to sexuality issues, breast cancer treatment centers can provide a place to address these issues and help patients deal with the after-effects of their treatment. As breast cancer survivor rates and disease-free intervals increase, the demand for a service that supports women returning to as near-normal a life as possible will only grow.

The international standard regimen of radiotherapy for women with early breast cancer following mastectomy or local tumour excision involves the delivery of daily doses (fractions) of 2.0 Gy to a total dose of 50 Gy. Recent randomised clinical trials suggest that there is most unlikely to be any disadvantages in terms of local tumour control or late adverse effects, and obvious advantages in terms of convenience, for schedules treating to a lower total dose using a smaller number of larger fractions. Fifteen or 16 fractions of 2.67 Gy are being adopted in some countries, and future research will test the limits of this approach, termed accelerated hypofractionation.