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Innovation and clinical specialities: oncology
of all breast cancers in countries with limited resources and has a
poor prognosis 12 . Locally advanced tumors include tumours that
present with palpable lymph node metastases, ulcerations, tumors
greater than 5 cm etc.
A subtype of LABC that deserves some further discussion is
Inflammatory Breast Cancer (IBC). Inflammatory breast cancer is a
rare but aggressive subtype of breast cancer, which historically
was considered uniformly fatal. Clinically, inflammatory breast
cancer is characterized by the rapid onset of breast warmth,
erythema, and edema (peau d’orange) often without a welldefined
mass.
Along with extensive breast involvement, women with
inflammatory carcinoma often have early involvement of the axillary
lymph nodes. In general, women with inflammatory breast cancer
present at a younger age are more likely to have metastatic
disease at diagnosis, and have shorter survival than women with
non-inflammatory breast cancer. 101-103 The management of LABC
requires a combined modality treatment approach involving
surgery, radiotherapy and systemic therapy.
Radiotherapy in LABC
Radiotherapy after MRM or mastectomy to the chest wall or axilla
is restricted to patients with high risk of recurrence. These include
tumors larger than 5 cm in maximum diameter and those with
four or more involved axillary lymph nodes, those with positive
surgical margins on resection, and those with involvement of the
skin or underlying chest wall. 12 It can also be a very effective local
modality in controlling or shrinking tumors that are not amenable
to surgical therapy.
Preoperative and locoregional treatment
The initial management should be neoadjuvant chemotherapy
with Doxorubicin- or Epirubicin-based or Paclitaxel- or Docetaxel
based chemotherapy. Patients with HER2 positive tumors should
be considered for preoperative chemotherapy incorporating
Trastuzumab.
The advantages of neoadjuvant therapy include down staging of
the tumor, improving operability of tumors and increasing the
chances of BCT.
For patients that respond to neoadjuvant chemotherapy, the
following options are recommended 71,104-108 modified radical
mastectomy, radiotherapy to the chest wall and supraclavicular
nodes (plus internal mammary nodes if involved) with or without
delayed breast reconstruction. In those women with LABC who do
not have access to neoadjuvant chemotherapy because of
economic constraints or radiotherapy, mastectomy with node
dissection, when feasible, may still be considered in an attempt to
achieve local-regional control. 12 The second option is BCT with
surgical axillary staging, radiotherapy to the breast, supraclavicular
nodes (plus internal mammary nodes if involved).
However, for patients who fail to respond to preoperative
chemotherapy, recommended treatment is to consider additional
systemic chemotherapy and/or preoperative radiation.
Adjuvant treatment
Chemotherapy should contain an anthracycline. Acceptable
regimens are 6 cycles of 5 Fluorouracil, Doxorubicin,
Cyclophosphamide (FAC) or Cyclophosphamide, Epirubicin,
5Fluorouracil (CEF). Sequential addition of Taxanes has also
proven very effective.
Tamoxifen for 5 years should be recommended to pre- and
postmenopausal women whose tumours are hormone responsive.
Aromatase inhibitors like Letrozole, Anastozole and Examestane
can be used in post menopausal patients.
Surgical oophorectomy causing ovarian ablation is a very
effective therapy in the treatment of locally advanced and
metastatic ER positive breast cancer in premenopausal women.
This therapy is one that would be very feasibly applied in Africa
provided that it was acceptable to the woman.
Metastastic and recurrent cancer
The standard evaluation procedure for this group of patients
includes history and clinical examination, full blood count, liver
function test, platelet count , chest X-ray, limited skeletal survey
especially of any long or weight bearing bones that are painful,
biopsy of recurrence, evaluation of hormone receptor status,
ultrasound of the abdomen or CT where available.
Others include bone scans, MRI, PET, and determination of
HER2 status of the tumor. These are however tall orders in
countries with limited resources and where there are no medical
insurances to cover the cost of these investigations. Pragmatism
is required in this setting.
Treatment of local recurrence
Local recurrence can occur in two settings; post BCT or MRM.
Post MRM local recurrence should undergo local resection of
the recurrence where feasible without unnecessarily endangering
the lives of the patients. In addition, radiotherapy of the involved
area should be done if the chest wall was not previously irradiated
or if it could be done safely.
Post BCT patients should undergo a total mastectomy.
Systemic therapy for local recurrence could be adjuvant
chemotherapy or endocrine therapy as in LABC.
Addition of Hyperthermia to radiotherapy has been shown in
some trials to cause a statistically significant increase in local
tumor response and greater duration of local control. This is
however technically demanding and resource intensive.
Systemic disease
Systemic recurrence and metastatic cancers are incurable, so the
goals of therapy are to prolong survival, improve quality of life with
minimal morbidity or toxicity from the therapy.
Minimally toxic endocrine therapy is therefore preferred to the
use of cytotoxic therapy whenever indicated. Endocrine therapies
are indicated in women with hormone receptor status, bone or
soft tissue disease only and those with limited asymptomatic
visceral disease. For post menopausal women, the choice is
between Tamoxifen and aromatase inhibitors, with aromatase
inhibitors having a slight edge especially in those who have taken
anti-estrogen previously.
For premenopausal women who are anti-estrogen naïve, antiestrogen
with or without LHRH agonist is the preferred choice.
Oophorectomy is an excellent cheap alternative where drugs are
not available.
Since the majority of African women with breast cancer are
hormone receptor negative, few will benefit from endocrine
therapy, chemotherapy will be the option in most cases.
Premenopausal patients who have taken anti-estrogen
100 Hospital and Healthcare Innovation Book 2009/2010