Ernesto Sánchez Forgach

Breast Cancer Care in Developing Countries

BackgroundBreast cancer is the commonest cancer of women the world over, and its incidence is rising, especially in developing countries, where the disease poses a major health care challenge. This growing incidence in developing countries reflects the advanced stage at diagnosis, low levels of public awareness of the risk for the disease, and poor medical infrastructure and expertise, with the resultant poor treatment outcomes.MethodsThis article provides a collective edited summary of the presentations at the symposium titled “Breast Cancer Care in Developing Countries,” held as part of the Breast Surgery International program at the International Surgical week 2007, Montreal, Canada, August 2007. The aim of the presentations was to bring out the diverse clinical pathological and outcomes-related facts of breast cancer care available to women in several countries. As the incidence of breast cancer continues to rise steadily in the developing world, the lack of awareness of this disease and the absence of breast cancer screening programs make it almost certain that the majority of breast cancers are diagnosed at an advanced stage. In addition, the quality of care available for breast cancer patients varies widely according to where the patient is treated.ResultsThough there are some centers of excellence providing multimodality protocol-based treatment on a par with the best anywhere in the world, most breast cancer patients receive inadequate and inappropriate treatment because of a lack of high-quality infrastructure—and sometimes skills—and, above all, because of limited financial resources.ConclusionsIn countries where these limitations are present, there is a need to emphasize public health education, promoting early diagnosis. In addition, resources must be directed toward the creation of more public facilities for cancer treatment. As these goals are met, it is likely that there will be a much-needed improvement in breast cancer care in developing countries.

Respuesta terapéutica a gemcitabina en cáncer de mama avanzado en relación con factores immunohistoquímicos

ResumenEl cáncer de mama avanzado tiene un pronóstico pobre. La gemcitabina, análogo de la desoxycitidina, muestra índices de resquesta entre el 25% y 37% en casos avanzados. Hemos evaluado la toxicidad y la eficacia de la gemcitabina en pacientes con cáncer de mama avanzado, previamente tratados y correlacionado las respuestas con los factores inmunohistoquímicos. Los pacientes fueron tratados con gemcitabina a dosis de 1.250 mg/m2 durante tres semanas cada mes por al menos dos ciclos. Se evaluó edad, HER2/neu,p53, receptores hormonales, angiogénesis, sitios y número de metástasis, número de ciclos recibidos, escala de Karnofsky, tiempo libre de progresión, sobrevida global y efectos adversos. De enero de 1996 a noviembre de 1999 se incluyeron 19 mujeres con edad promedio 52,3±12,7; rango: 31 a 84 años. Los factores immunohistoquímicos fueron determinados en 10 pacientes; el 56,2% resultaron positivos. La sobreexpresión del HER2/neu se encontró en 5 pacientes,p53 en 5, receptores de estrógenos en 4 y progesterona en tres. La gemcitabina fue administrada como segunda línea terapéutica en 6 pacientes, tercera en 6, cuarta en 3, quinta en uno y sexta en uno. La escala de Karnosfky promedio al inicio del tratamiento fue de 81,05±11; rango; 70 a 100; después del segundo o tercer ciclo fue de 82,1±11,3 (60 a 100) y al final 78,9±11,5 (60 a 100), p=0,666. Los pacientes recibieron de 2 a 10 ciclos de tratamiento. El número de sitios con metástasis fue 2,7±1,2; rango: 1 a 5. Se observaron dos respuestas completas (10,5%), parciales 6 (31,5%), índice de respuesta 42% y estatismo 7 y progresión en 4. El tiempo libre de progresión promedio fue de 8,5±4,8 meses (2 a 19). La sobrevida global fue de 10,4±6,8 meses (2 a 23). Catorce pacientes murieron con actividad tumoral (73,6%); 4 se encuentran vivos con actividad (21%) y uno sin actividad. No identificanos relación entre la respuesta tumoral y los factores inmunohistoquímicos HER2/neu, p=0,519;p53, p=0,519; receptores estrogénicos, 0,236, y de progesterona, 0,673. Se observaron efectos adversos en 9 pacientes, trombocitopenia grado I-II en 7, anemia grados II-III en 5 y neutropenia grados II-III en tres. Náusea y vómito, disuria y alopecia en dos pacientes. La gemcitabina muestra ser activa en pacientes con cáncer de mama avanzado previamente tratados, con bajo grado de efectos adversos. No se mostró relación entre las respuestas tumorales y los factores immunohistoquímicos.AbstractAdvanced breast cancer has a poor prognosis. Gemcitabine, a desoxycitidine analogue, has shown 25% to 37% overall response in advanced cases. We have evaluated the efficacy and safety of gemcitabine in patients with advanced breast cancer heavily pretreated and to correlated responses with immunohistochemical factors. Patients were treated at doses of 1,250 mg/m2/week/q/month, for at least two cycles. Age, HER2/neu,p53, hormonal receptors, angiogenesis, site and number of metastases, number of cycles received, Karnofskys score, progression free survival, overall survival and side effects were evaluated.From January 1996 to November 1999, 19 women were included, mean age 52.3±12.7; range: 31 to 84 years. Immunohistochemical factors were determined in 10 patients and resulted positive 52.6%; overexpression of c-erbB-2 in 5 patients,p53 in 5, estrogen receptor in 4, progesterone receptor in 3. Gemcitabine was applied as second line in 6 patients, third in 6, fourth in 3, fifth in one and sixth in one too. Mean Karnofsky score at the start of treatment 81.05±11; range: 70 to 100: after second and third cycles 82.1±11.3 (60–100) and at the end 78.9±11.5 (60–100); p=0.666. Patients received 2–10 cycles of treatment. Mean metastasic sites 2.7±1.2; range: 1 to 5; two complete responses, 10.5%; partial 6 (31.5%), response rate 42%, stable 7 and progression 4. Progression free survival 8.5±4.8 months, range 2 to 19. Overall survival 10.4±6.8 mos, two to 23. Forteen patients have died with tumor (73.6%), 4 are alive with tumor (21%); and only one is alive without tumor. We did not identify relationship between tumor response and immunohistochemical factors, c-erbB-2, p=0.519;p53, p=0.519; estrogen receptor, p=0.236 and progesterone receptor; p=0.673. Side effects were observed in 9, thrombocytopenia grade I-II in 5 patients, neutropenia grade I-II in 7 and anemia grade II-III in 3. Nausea, vomiting, dysuria and alopecia in two patients.Gemcitabine is active in heavily pretreated advanced breast cancer patients showing low grade side effects. Apparently, there is not relationship between tumor response and immunohistochemical factors.