An overview of multimodal treatment and a tribute to resilient women
James Fleck: Anticancerweb 12 (02), 2021
Worldwide, more than 2.2 million women are diagnosed with invasive breast cancer each year. The World Health Organization (WHO) estimates an ASR = 47.8 (47.8 cases / 100,000), making breast cancer the most common malignant tumor in women. Fortunately, there is a very effective multimodal treatment. The average 5-year survival rate for non-metastatic invasive breast cancer is 91% and if the tumor is located only in the breast, without lymphatic spread, the 5-year survival rate reaches 99%. In addition, public education and technical advances in mammography were responsible for stage I diagnosis in 62% of American women. Currently, molecular diagnosis has also increased treatment specificity. Special attention has been given to triple-negative breast cancer (TNBC), which does not express receptors for estrogen, progesterone and Her-2. The 5-year survival rate tends to be lower in TNBC, making this molecular subtype a high priority for clinical trials. Fortunately, TNBC accounts for only 10-15% of breast cancer diagnosis. Most breast cancer patients (70%) have a luminal type, with a better prognosis.
Early breast cancer is defined as a localized (stage I) or regional disease (stage II), including a tumor up to 5 cm in diameter (T2) and positive lymph nodes (N1). This concept includes a wide range of breast cancer patients that can be cured using multimodal therapy. Multimodal therapy consists of surgery, radiation therapy and adjuvant or neoadjuvant systemic treatment. Whenever possible, conservative breast surgery (lumpectomy) should be recommended, as it provides equivalent survival to that of mastectomy and is cosmetically superior. Surgery also include, sentinel lymph node biopsy (SLB). Breast-conserving treatment must always be accompanied by radiation therapy. Systemic adjuvant treatment will depend on the characteristics of the tumor. Women with early stage Her2-negative, hormone-receptor (HR)-positive breast cancer should be treated with adjuvant endocrine therapy. The additional use of adjuvant chemotherapy is based on high-risk clinical characteristics ( T ≥ 2cm, N1) and evaluation of genetic phenotype provided by breast cancer multigene prognostic tests (oncotype DX and Mamma Print). TNBC (T ≥ 0.5 cm) should be treated with adjuvant chemotherapy. Her2-positive breast cancer patients (T ≥ 1 cm) should be treated with adjuvant chemotherapy and trastuzumab / pertuzumab. Following chemotherapy patients Her2-positive and HR-positive should receive endocrine therapy. The duration of treatment depends on the molecular subtype. Toxicity is manageable, since adjuvant treatment has a high therapeutic index. Whole breast radiation therapy (WBRT) should be administered to most patients undergoing conservative surgery. The timing is determined by molecular classifications and systemic adjuvant treatment recommendation. Patients treated with adjuvant chemotherapy should receive WBRT upon completion. Her2-positive early breast cancer can receive WBRT concomitant with trastuzumab / pertuzumab and HR-positive patients generally have WBRT before or concomitantly with endocrine therapy. The importance of using post-operative WBRT was well demonstrated in a metanalysis conducted by the Early Breast Cancer Triallists’ Collaborative Group revealing a significant reduction in 10-years of first recurrence risk (RR = 0.52) and 15-years risk of cancer death (RR = 0.82) when compared to conservative breast surgery alone. Currently, WBRT has been administered in a more convenient and less toxic hypofractionated schedule, using a larger fraction, but with a shorter duration. Usually, it reduces the duration of the WBRT by 2 weeks. This is also important for the public health system, since a greater number of patients can be treated with post-operative WBRT. High-risk early-breast cancer patients (N1, high-grade T2-tumor, HR-negative T2-tumor or T2-tumor expressing lymphovascular invasion) should also receive regional nodal irradiation (supra and infraclavicular LN, internal mammary nodes and axilla, in patients spared from axillary dissection). Recently, the equivalence of the two irradiation schedules (5 weeks-conventional x 3 weeks-hypofractionated) has also been demonstrated in patients with locally advanced (stage III) breast cancer treated with mastectomy. Finally, we need to recognize the effort and determination of an increasing number of more than 2 million resilient women / year, worldwide. Fighting breast cancer, they have no face, despite being primarily responsible for each sequential therapeutic achievement shown in this breast cancer multidisciplinary approach.
References:
1. World Health Organization (WHO): Global Cancer Observatory, 2018
2. Darby S, McGale P, Correa C, Taylor C, et al: Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10,801 women in 17 randomised trials. Early Breast Cancer Trialists' Collaborative Group (EBCTCG), Lancet378(9804): 1707-16, 2011
3. Hickey BE, James ML, Lehman M, et al: Fraction size in radiation therapy for breast conservation in early breast cancer, Cochrane Database Syst Rev., Jul 18th, 2016
4. Shu-Lian Wang, Hui Fang, Yong-Wen Song, et al: Hypofractionated versus conventional fractionated postmastectomy radiotherapy for patients with high-risk breast cancer: a randomised, non-inferiority, open-label, phase 3 trial, Lancet Oncol, January 30th , 2019
5. Photo by Vonecia Carswell on Unsplash modified by Fernanda Leal
There is a situation in which the resilience of women battling breast cancer must be especially recognized: pregnancy-associated breast cancer (PABC). Breast cancer is the most common neoplasm during pregnancy and, although pregnancy itself is not a bad prognostic factor, the physiological changes that occur in the breast during pregnancy can delay the diagnosis. In addition, the most common type of cancer in women who are in the reproductive period is triple-negative breast cancer, which has fewer therapeutic options. Thus, women who are forced to fight for their lives while generating a new one deserve a special tribute.
Breast cancer, being the most common incident malignancy in women has been over the time explored by the medical scientific community as a study target (and extraordinary learning in cancer follows), with the application of the most diverse diagnostic tools and techniques, as well as the therapeutic interventions for curative and preventive purposes. The advanced biotechnologies, genetics and artificial intelligence, certainly contributed to the improvement and use of better clinical investigations that have helped in the settlement of early diagnosis with favorable prognosis, in addition to more specific treatments with the maximum efficacy and minimum possible occurrence of side effects.
The information covered in this article is extremely important, both for the scientific community and for the general population, since breast cancer is considered the most common malignancy in women (2.2 million diagnoses per year worldwide). In this sense, I found the article very enlightening from an educational point of view, as it presented data on the worldwide incidence of breast cancer, as well as updated treatments and survival rates.
It is very encouraging for a woman who was received a breast cancer diagnosis to have this overview of the disease's treatment, since such great average 5-year survival can provide some comfort in a difficult time. It is very important to spread this information as well as treatment options in order to break a barrier of death that some people may associate the cancer with, besides provide a more accurate scenario for these resilient women in challenging times.
This text was extremely enlightening and information like this should be disseminated to the general population. For the vast majority of women who are diagnosed with breast cancer, they often see it as the end of life and do not have the idea that it is possible to be cured or live for many years with the disease, as a chronic disease. Many patients still see cancer as synonymous with death, as a taboo and sometimes they don't even like to mention the word. Public awareness of cure, survival, treatments and technological advances in therapeutic interventions should be encouraged. The title of the text by itself is already extremely interesting and demonstrates a reality that is not yet part of common sense.
Breast cancer represents a huge stigma among women, due to the fear of mutilation and the loss of their femininity. The breasts are seen as an expression of the female image, and total mastectomy is viewed with great anxiety due to its aggressiveness. Fortunately, with the advent of new therapies, today multimodal treatment is employed, as mentioned above, preserving what is possible of the breast, making its reconstruction possible with more tranquility. The technological advances have allowed women affected by this disease to rescue their own identity, besides increasing their survival.
Early diagnosis of breast cancer is essential for a cure. A current therapeutic approach is multimodal treatment, which is highly effective. This treatment includes surgery, radiotherapy, and systemic therapy, highlighting the significance of early diagnosis and advancements in mammography techniques. It's worth noting that different subtypes of breast cancer have distinct specific treatments. Additionally, post-operative radiotherapy and advancements in its administration are crucial, enabling shorter treatment durations. Finally, we must acknowledge the courage and determination of women worldwide who face breast cancer.
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