Breast cancer –

By Dr. Gaurav Jain

Intern Hidurao Hospital

 

Cancer refers to a rapidly multiplying mass of functionally and morphologically abnormal cells of malignant character, when such a growth occurs in the breast tissue it is diagnosed as breast cancer. Indian women are a growing race of sufferers with more and more new cases diagnosed every year. There is spreading awareness about self examination and diagnosis of breast cancer from mammograms and biopsies. The treatment of 1^st stage cancer is also typically followed up by localized radiation and chemotherapy or hormonal therapy using Selective Estrogen Receptor Modulators (SERMs) as Tamoxifen.

It is the protocol after this that is strangely disorganized; there are wide variations in the regimes by individual oncologists. The fact remains that most patients still report to their family doctors about whether to take the treatment, and what additional drugs or diet do they recommend. I try to put forward some additional information about some of the drugs and treatment protocols which the common doctor is unaware of.

 

The most common spread of breast cancer is to the adjacent lymph nodes or those above the clavicle, other sites are the bones, liver, brain and the lungs and hilar nodes. The risk for metastasis rises with factors as:

-         The lager the tumor was initially

-         The longer it remained untreated

-         The number of interventions (>2 FNACs are supposed to increase risk of spread)

-         The older the individual

-         Genetic factors as BRCA1 & 2 gene expression

-         Obesity and high estrogen levels

-         Dysmenorrheal complaints and past history of ovarian cancers.

 

Most oncologists monitor the liver function and the blood counts post chemotherapy with chest x-rays for hilar engorgements, some institutes advise yearly PET scans for metastatic disease. Recently with the increasing availability of finer sections on CECT or MRI with gadolinium contrast these techniques are being used too. Some British colleges advocate a three point ultrasound, of the contra lateral breast, abdomen and neck to look for masses or enlarged nodes to be of equal diagnostic importance. PCR tests like oncotype DX or microarray tests like MammaPrint predict cancer recurrence based on gene expression.

 

In a condition of metastasis, which should be detected early in patients undergoing regular checkups, the role of the family gynecologist or the doctor becomes more important. The patient seeks not only condolescence but also advice on treatment and additional drug complaints. And although there is no definite treatment regime one can advise, there are a few things to be known.

The treatment of such conditions cannot be radical surgery or localized radiation. The modalities of treatment are henceforth divided into certain groups.

 

a. Chemotherapy. This is the traditional approach and  is based on preventing cancer cells from dividing and hoping that they die of the oxidative stress produced or of their own old age. These include drugs as Taxanes (paclitaxel, docitaxel), Platinum based drugs (carboplatin, cisplatin), vinka alkaloids etc.
            Capecitabine (Xeloda) an oral precursor to fluorouracil is also advocated in failure or resistance.

 

b. Hormonal therapy. This treatment depends on the receptor assay of the tumor and is often instituted as the 1^st line therapy. The common ones are
            - Selective estrogen receptor modulators : Tamoxifen, Raloxifen
            - Aromatase Inhibitors : Anastrole, Exemestole, Letrozole.
            - Progesterogens : Megestrol Acetate.
            - Selective Progesterone receptor inhibitor : Mifepristone
            - Selective Progestrone receptor modulators : Asoprisnil, Progenta (CBD-4124)

 

c. Immunotherapy. Antibodies can inhibit or modulate certain receptors present on the cancer cells to help regulate rates of proliferation. It is also a targeted approach, but these are not wonder bullets but surely costly helpers
            - Trastuzumab (Herceptin) : The most famous of these drugs acts on HER2/neu receptor positive tumors by reducing their multiplication rates.
            - Bevacizumab (Avastin) : It is a monoclonal antibody against vascular endothelial growth factor (VEGF) inhibiting tumor growth by preventing neovascularization.
            - Lapatinib (Tykerb) : An ATP competitive epidermal growth factor receptor and HER2/neu dual tyrosine kinase inhibitor, an upcoming 1^st line therapy of oral use.

 

d. Radioimmunotherapy. This uses radioactively labeled antibodies to target cancer cells and kill then with radiation, using ²¹³Bi (α emitter).

 

e. Interstitial laser thermotherapy. Smaller tumor masses can be removed as palliative therapy or to protect infiltration of major vessels if paravascular nodes are involved.

 

With a long list of possible combinations the treatment for metastasis in breast cancer has improved the patient prognosis in terms of longevity and quality of life. It may interest you that some researches are promising a cure, Lodamin for one is a drug with properties against neovascularization that can help. A complete cure however is still awaited.

 

________________________________________________________________________