Living with advanced breast cancer

This article is intended for Healthcare Professionals

Thought LeadersDr. Javier CortesHead of Breast Cancer ProgramIOB Institute of Oncology

An interview with Dr Javier Cortes, Head of Breast Cancer Program, IOB Institute of Oncology, Madrid and Barcelona, Spain.

When does breast cancer become “advanced”?

There is a certain amount of debate surrounding the exact definition of advanced breast cancer (ABC). When we talk about clinical trials, it’s not easy to define.

In locally advanced breast cancer, the tumour is usually around 5cm or higher, and/or it has spread into the lymph nodes, the axilla, the internal mammary nodes or the infra and supraclavicular nodes.[1],[2] With metastatic breast cancer (MBC), we define patients with this spread as a ‘metastasis’.

In general, advanced breast cancer, as we are talking today, means that we cannot cure these patients.[3] The tumour is not in a local regional area, or if it is there we cannot operate to remove the tumour.[4]  That’s the concept of advanced breast cancer, in general.

Triple negative breast cancer and HER2+ are seen as very aggressive breast cancers compared to their counterparts, [5],[6] such as estrogen receptor-positive (ER+) and HER2- breast cancers, that are generally seen as not aggressive breast cancers by comparison.[7],[8]

Why are there differences in patient response to chemotherapy?

There are many different mechanisms of resistance to chemotherapy. In general, it depends on the tumour type. For example, triple negative tumours are quite sensitive to chemotherapy but this sensitivity is only seen initially.[5]

There are many proteins which are involved as a mechanism of resistance and it can be expressed higher in some tumour types compared with others.[9] In general, triple negative and HER2+ are more sensitive to chemotherapy than luminal (hormone receptor positive) cancers.[10],[11],[12]

What factors do oncologists need to consider when determining the most suitable treatment for their patients?

I think there are many factors, but I consider one of the most important is the tumour type. After this comes the amount of the disease that’s present in the patient.

If you have a patient with an estrogen-receptor positive tumour, usually we should think about endocrine therapy.[13] When it comes to HER2+ ABC, we generally consider combination therapies.[14] In triple-negative, clearly we have to think about chemotherapy (alone or in combination).[5]

How might living with MBC impact a patient in ways other than physically?

It is extremely important to consider the way that MBC can impact a patient psychologically.[15] A lot of patients find it emotionally difficult to know that they are living with cancer, especially in the case of MBC when they know that it cannot be cured. It’s very important for clinicians to take time to talk to patients; not just about chemotherapy, but about their lives and how their lifestyles will need to change it terms of what they can and can’t do, and help them come to terms with the life that they are going to have.

As healthcare professionals, it is important to be optimistic but honest with our patients. There are some patients who can live longer, and there are patients who will not die because of the disease. The quality of life could be very good in many, many patients. Providing these positive comments is very important for patients because, for me, I consider the psychological effects of living with advanced cancer more important to consider upon diagnosis, compared to the physical adverse effects that a patient with advanced cancer might have.

Please outline the importance of advocacy groups for individuals with breast cancer.

It generally varies between countries, but where patient advocacy groups are strong, they are truly amazing and do a great job in boosting the psychological impact of patients living with metastatic breast cancer.

What challenges do oncologists face when delivering the diagnosis of advanced breast cancer?

We, as healthcare professionals, tend to overestimate our abilities to talk to patients.[16] Sometimes we can have the help of psychologists, of course, but we have to talk to our patients in a friendly but factual way.

Oncologists know a lot about chemotherapy, endocrine therapy, targeted therapy etc, but at the end of the day what we must remember is that we are not just treating breast cancer – we are treating a human being with breast cancer.

I think that we, as oncologists, sometimes forget the reason why we are physicians. We attend conferences, give talks, and are generally very busy people. If we forget that everything we do is for the patient at the heart of the condition, then this is when delivering breast cancer diagnosis becomes challenging.  

About Dr Javier Cortes

Dr. Javier Cortes received a degree in Medicine and Surgery from the Universidad Autónoma de Madrid in 1996. He continued his studies at the University of Navarra, specialising in Medical Oncology at the Clínica Universitaria de Navarra, where he continued as Assistant in the Department of Oncology from 2002.

He was Associated Professor of Oncology in the Faculty of Medicine at the University of Navarra during that period. Dr. Cortés was awarded the title of Doctor in Medical Oncology from the University of Navarra in 2002.

From June 2003 to July 2015, he has worked in the Department of Medical Oncology at the Hospital Vall d'Hebron, Barcelona, where he has been Coordinator of the Teaching and Training Programme for Residents in Oncology and Senior Specialist in the Area of Breast Cancer with a special interest in New Drugs Development. Dr. Cortés was the Head of the Breast Cancer Program and the Melanoma Unit from July 2006 to August 2015.

From September 2015 to October 2018, he has been Head of the Breast Cancer and Gynecological tumors at Ramon y Cajal University Hospital in Madrid. Currently, he is Clinical Investigator of the Breast Cancer Research Program at Vall d’Hebron Institute of Oncology, and Head of Breast Cancer Program, IOB Institute of Oncology, Madrid and Barcelona, Spain.

This article is intended for Healthcare Professionals

EMEA-HAL-19-00048

June 2019

Sources:

[1] Giordano S, Update on Locally Advanced Breast Cancer. The Oncologist. 2003;8(6):521-530.

[2] Best Practice BMJ. Metastatic breast cancer. 2019. Available at: https://bestpractice.bmj.com/topics/en-gb/718. Accessed June 2019.

[3] Hattori M, & Iwata H, Advances in treatment and care in metastatic breast cancer (MBC): are there MBC patients who are curable? Chin Clin Oncol. 2018;7(3):23.

[4] Garg PK & Prakash G, Current definition of locally advanced breast cancer. Curr Oncol. 2015;22(5):e409–e410.

[5] Yao H, et al. Triple-negative breast cancer: is there a treatment on the horizon?. Oncotarget. 2017;8(1):1913–1924.

[6] Colomer R, et al. Real-world treatment in patients with HER2+ metastatic breast cancer: Treatment decisions in HER2+ mBC. Breast Cancer Res Treat. 2018;168(1):197–205.

[7] Nasrazadani A, et al. Precision Medicine in Hormone Receptor-Positive Breast Cancer. Frontiers in Oncology. 2018;8:144.

[8] VeryWell Health. HER2 Positive vs. HER2 Negative Breast Cancer. 2019. Available at: https://www.verywellhealth.com/her2-positive-vs-her2-negative-breast-cancer-4151792. Accessed June 2019.

[9] Chun KH, et al. Predicting and Overcoming Chemotherapeutic Resistance in Breast Cancer. Adv Exp Med Biol. 2017;1026:59-104.

[10] Mayo clinic. Breast cancer types: What your type means. Available at: https://www.mayoclinic.org/diseases-conditions/breast-cancer/in-depth/breast-cancer/art-20045654. Accessed June 2019.

[11] Yam C, et al. Targeting the Molecular Subtypes of Triple Negative Breast Cancer: Understanding the Diversity to Progress the Field. Oncologist. 2017;22(9):1086–1093.

[12] Yersal O, Barutca S, Biological subtypes of breast cancer: Prognostic and therapeutic implications. World J Clin Oncol. 2014;5(3):412–424.

[13] Fan W, et al. Endocrine therapy resistance in breast cancer: current status, possible mechanisms and overcoming strategies. Future Med Chem. 2015;7(12):1511–1519.

[14] Cardoso F, et al. 4th ESO–ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC 4). Annals of Oncology. 2018;29: 1634–1657.

[15] Giese-Davis J, et al. Depression and stress reactivity in metastatic breast cancer. Psychosom Med. 2006 Sep-Oct;68(5):675-683.

[16] Ha JF, & Longnecker N, Doctor-patient communication: a review. Ochsner J. 2010;10(1):38–43

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