04. Breast cancer (neo and adjuvant)
Breast cancer is one of the leading causes of death in the world in the female gender.
Outcomes for breast cancer vary depending on the cancer type, extent of disease, and patient’s age. Survival rates in the developed world are high, between 80% and 90%, of those in England and the United States alive for at least 5 years. In developing countries survival rates are poorer. Worldwide, breast cancer is the leading type of cancer in women, accounting for 25% of all cases. In 2012, there were registered 1.68 million new cases and 522,000 deaths. It is more common in developed countries, and a 100 times more frequent in women, than in men.
There are currently three main groups of medications used for adjuvant breast cancer treatment: hormone-blocking agents, chemotherapy, and monoclonal antibodies
Hormone blocking therapy
Some breast cancers require estrogen to continue growing. They can be identified by the presence of estrogen receptors (ER+) and progesterone receptors (PR+) on their surface (also known as hormone receptors). These ER+ cancers can be treated with drugs that either block the receptors, e.g. tamoxifen, or alternatively block the production of estrogen with an aromatase inhibitor, e.g. anastrozole or letrozole. The use of tamoxifen is recommended for 10 years. Letrozole is recommended for 5 years. Aromatase inhibitors are only suitable for women after menopause; however, in this group, they work better than tamoxifen. This is because the active aromatase in postmenopausal women is different from the prevalent form in premenopausal women, and therefore these agents are ineffective in inhibiting the predominant aromatase of premenopausal women. Aromatase inhibitors should not be given to premenopausal women with intact ovarian function (unless they are also on treatment to stop their ovaries from working). CDK inhibitors can be used in combination with endocrine or aromatase therapy.
Chemotherapy is predominantly used for cases of breast cancer in stages 2–4, and is particularly beneficial in estrogen receptor-negative (ER-) disease. The chemotherapy drugs are administered in combinations, usually for periods of 3–6 months. One of the most common regimens, known as “AC”, combines cyclophosphamide with doxorubicin. Sometimes a taxane drug, such as docetaxel, is added, and the regime is then known as “CAT”. Another common treatment is cyclophosphamide, methotrexate, and fluorouracil (or “CMF”). Most chemotherapy medications work by destroying fast-growing and/or fast-replicating cancer cells, either by causing DNA damage upon replication or by other mechanisms. However, these type of medications also damage fast-growing normal cells, which may cause serious side effects. Damage to the heart muscle is the most dangerous complication of doxorubicin, for example.
Trastuzumab, a monoclonal antibody to HER2, has improved the 5-year disease free survival of stage 1–3 HER2-positive breast cancers to about 87% (overall survival 95%). Between 25% and 30% of breast cancers overexpress the HER2 gene or its protein product, and overexpression of HER2 in breast cancer is associated with increased disease recurrence and worse prognosis. Trastuzumab, however, is very expensive, and its use may cause serious side effects (approximately 2% of people who receive it develop significant heart damage). Another antibody pertuzumab prevents HER2 dimerization and is recommended together with trastuzumab and chemotherapy in severe disease.
This module will provide more details regarding the different strategies of adjuvant therapy and a comprehensive look on metronomic chemotherapy studies.
- Lectures 16
- Quizzes 1
- Duration 1 hour
- Skill level Any
- Language English
- Students 0
- Assessments Yes
Lesson 1 Emilia Montagna
Neoadjuvant treatment in breast cancer: current approach and new treatment options
Lesson 2 Elisabetta Munzone
Metronomics in the neoadjuvant treatment of breast cancer
Lesson 3 Sven Langkjer
Adjuvant treatment in breast cancer: Current strategies and Future Perspectives
Lesson 4 Marina Elena Cazzaniga
Metronomics in the adjuvant treatment of breast cancer
The quiz is mandatory only for those willing to achieve European CME credits. Please be aware that the ISMe® educational e-learning platform is in the process of being accredited by the European Accreditation Council for Continuing Medical Education (UEMS-EACCME)