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Innovation and clinical specialities: oncology
previously have a choice of either surgical or radiotherapeutic
oophorectomy or luteinizing hormone-releasing hormone (LHRH)
agonists with or without an antiestrogen.
Endocrine therapies in postmenopausal women include
selective, nonsteroidal aromatase inhibitors (anastrozole and
letrozole); steroidal aromatase inhibitors (exemestane); pure
antiestrogens (fulvestrant); progestin (megestrol acetate);
androgens (fluoxymesterone); and high-dose estrogen (ethinyl
estradiol). In premenopausal women, therapies include LHRH
agonists (goserelin and luprolide); surgical or radiotherapeutic
oophorectomy; progestin (megestrol acetate); androgens
(fluoxymesterone); and high-dose estrogen (ethinyl estradiol).
Chemotherapy is the best option in women with estrogen and
progesterone receptor-negative tumors, symptomatic visceral
metastasis, or endocrine therapy refractory disease.
The higher rates of objective response and longer time to
progression of combination chemotherapy are at the expense of
increased toxicity with little survival benefit.
Therefore, there is no significant advantage of combination
chemotherapy over sequential single agents.
Preferred first-line chemotherapies include sequential single
agents or combination chemotherapy. Among preferred first-line
single agents, are doxorubicin, epirubicin, pegylated liposomal
doxorubicin, paclitaxel, docetaxel, capecitabine, vinorelbine (all
category 2A), and gemcitabine (category 2B). Among preferred
first-line combination regimens are cyclophosphamide,
doxorubicin, and fluorouracil (FAC/CAF); fluorouracil, epirubicin,
cyclophosphamide (FEC); doxorubicin, cyclophosphamide (AC);
epirubicin, cyclophosphamide (EC); doxorubicin in combination
with either docetaxel or paclitaxel (AT); cyclophosphamide,
methotrexate, fluorouracil (CMF); docetaxel, capecitabine;
gemcitabine, paclitaxel.
Patients with tumors that are HER2-positive may derive benefit
from treatment with trastuzumab as a single agent or in
combination with selected chemotherapeutic agents. 27% of
patients treated with a combination of Trastuzumab and
doxorubicin/cyclophosphamide chemotherapy develop significant
cardiac dysfunction making this regime unsafe and unpopular. 71
Treatment of complications
In Africa, a good number of women present with fungating/
ulcerating masses and many of them are so ill that they can not
undergo surgery or radiotherapy immediately. The following are
some useful supportive measures:
✚ Dressing of the wound with honey and metronidazole
cleanses and remove the odor. This measure in addition to the
use of neoadjuvant chemotherapy has largely reduced the
need for toilet mastectomy.
✚ Clean malignant ulcers are prone to secondary hemorrhage;
topical formalin is effective in this setting.
✚ Pain is another significant problem and this may be due to the
disease, therapy or depression. Optimal pain management is
very crucial to improving the quality of life. If pain occurs, there
should be prompt oral administration of drugs in the following
order: non-opioids (aspirin and paracetamol); then, as
necessary, mild opioids (codeine); then strong opioids such as
morphine, until the patient is free of pain. To calm fears and
anxiety, additional drugs – “adjuvants” – should be used. To
maintain freedom from pain, drugs should be given “by the
clock”, that is every 3-6 hours, rather than “on demand” This
three-step approach (see figure 2) of administering the right
drug in the right dose at the right time is inexpensive and 80-
90% effective. Surgical intervention on appropriate nerves may
provide further pain relief if drugs are not wholly effective. 109
✚ Anemia as a result of the disease or chemotherapy is often
under treated and underestimated in patients. It has a negative
impact on quality of life and survival. It will require blood
transfusion in some women. The introduction of recombinant
human erythropoietin (epoetin) has provided an effective and
convenient treatment of anemia without the risks of blood
transfusion. Epoetin is also effective for the prevention of
anemia and reduction of transfusion requirements in patients
with a high risk of developing anemia during chemotherapy. 110-112
✚ Lymphedema of the arm is a very distressing complication
which may occur as a result of the disease itself or as a result
of surgery or radiotherapy in the treatment of breast cancer.
Treatment options include compression treatments (using
compression bandage or garments and pneumatic
compression devices), therapeutic exercises and
pharmacotherapy (antibiotics, flavonoids, hyaluronidase, and
selenium). Diuretics have not been found useful. 113,114
✚ Respiratory distress in advanced breast cancer may be as a
result of pleural effusion or deposits in the lungs. Closed
thoracostomy tube drainage with pleurodesis using
Tetracycline or Bleomycin is an effective treatment. Lung
metastasis can be treated with steroids inhalers, bronchodilators,
diuretics, anxiolytics, chest physiotherapy and oxygen. 5
✚ Neurological complications include cerebral metastases,
spinal, leptomeningeal, cranial and peripheral nerve
metastases. 115 Treatment includes steroids,
radiotherapy and surgery for localized metastases.
Younger women with breast cancer are more prone to physical
and psychological distress which makes them have poorer quality
of life outcomes. These arise as a result of the disease and the
complications of treatment. Gonadal toxicity leading to irregular
menses, amenorrhea and premature menopause is especially
disturbing for African patients, the majority of whom are in their
reproductive age group. Other problems like Alopecia, fertility
problems and the cost of treatment may severely affect
relationship especially among young couples. In this context, a
multi disciplinary approach is important which will involve
psychologists, social welfare/support groups and various
advocacy groups where survivors of breast cancer can share their
experiences and support one another. 116-120
Prognosis
Natural history
The natural history of breast cancer in 250 untreated women
revealed the following statistics; Median survival of untreated breast
cancer was 2.7 years after initial diagnosis. The 5- and 10-year
survival rates were 18.0 and 3.6%, respectively. Only 0.8% survived
for 15 years or longer. Autopsy data confirmed that 95% of these
women died of breast cancer, while the remaining 5% died of other
causes. Almost 75% of the women developed ulceration of the
breast during the course of the disease. The longest surviving
patient died in the nineteenth year after diagnosis. 121
With modern treatment, the 5-year survival rate for stage I
Hospital and Healthcare Innovation Book 2009/2010 101