VMPL
Faridabad (Haryana) [India], October 30: A 26 year old woman with triple negative breast cancer of the left breast and a single lung metastasis has been the subject of a lot of discussion in the context of the increasing use of individualised, multi-disciplinary management of patients with complex breast cancer.
The patient had a treatment plan which involved chemo, surgery and radiotherapy with Dr Praveen Kumar Bansal (Director – Oncology Services, Metro Cancer Institute).
The case is very much pertinent in the context of Breast Cancer Awareness Month. It serves to illustrate two key points: that breast cancer can strike women at a younger age and that treatment is now very much dictated by the biology of the cancer and its stage rather than by a one size fits all approach.
Triple negative breast cancer is a subtype in which the tumour is negative for both the oestrogen receptor and the progesterone receptor as well as HER2. The management of this form of the disease is therefore very different from that of a number of the other forms of breast cancer.
As Dr Bansal points out, modern breast cancer management is very much dependent on accurate diagnosis, staging and assessment of the tumour biology.
"Current treatment decisions are increasingly individualised. We look at the stage of disease, the tumour subtype, the response to therapy, the patient's overall health and a whole host of other clinical factors before arriving at a treatment strategy. In complex cases we may well find that a combination of different modalities is the way to go in order to get at both the local and the systemic disease," he said.
In this case there was a single lung metastasis and so comprehensive staging was of paramount importance. Chemotherapy formed part of the systemic management, with surgery and radiotherapy subsequently delivered in accordance with the patient's clinical response and overall clinical picture.
There's been a huge advance in the care of breast cancer over the past 10 years. Depending on the subtype of tumour and the disease profile, patients can now be considered for a range of treatments including chemo, modern surgery, precision radiotherapy, targeted therapy and immunotherapy.
For TNBC chemotherapy remains an important part of the treatment. In some patients there may be a role for newer systemic therapies (e.g. immunotherapy) depending on the biomarker profile and other clinical factors.
Improved imaging, pathology and biomarker testing have all altered the way we assess breast cancer. They allow the oncologist to get a much better understanding of what the tumour is going to do and hence what the best course of management is for that individual patient.
Surgical options have also changed. Breast conservation can be an option in appropriate cases and modern radiotherapy techniques allow for more targeted treatment with much greater effort to minimise the exposure of the surrounding healthy tissue.
For younger women the diagnosis of breast cancer brings with it a whole raft of other issues beyond the treatment of the cancer itself. Fertility, body image, emotional health, future family planning and long term quality of life are all issues which may come into the treatment discussion and will all require appropriate counselling.
Dr Bansal said younger women shouldn't assume that persistent breast changes are of no significance just because they're young.
'Any persistent breast lump, any change in the shape or size of the breast, nipple changes, any unusual discharge or skin changes should be seen by a doctor. Young age in no way rules out the possibility of breast cancer and indeed delaying evaluation can also lead to a delay in diagnosis,' he said.
The case is a good example of the move in oncology towards multidisciplinary cancer care with the various specialists (medical oncologist, surgeon, radiation oncologist, radiologist and pathologist) all involved in working out what the best approach to management should be.
Breast Cancer Awareness Month continues to drive home the message that awareness is important at all ages. Breast cancer is of course more common in the older age groups but younger women can get it too, including the more biologically aggressive forms.
As the options for diagnosis and treatment continue to improve the emphasis is increasingly on earlier recognition, accurate staging and individualised management.
The broader message from the case is that treatment of breast cancer is becoming increasingly targeted and that access to coordinated, high quality care can open up more treatment options even in the most complex of cases.
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