The goal is to heal and, when not possible, to extend the life of the patients as much as possible. Limiting for side effects, avoiding unnecessary chemotherapy and using new targeted drugs
Reduce the risk of relapse, lengthen survival, reach the goal of healing whenever possible and achieve these results using therapies that are as least toxic as possible. These are the objectives achieved by various trials on breast cancer presented during the congress of the American Society of Oncology (Asco), just finished in Chicago. If the idea behind the treatments was, up until a few years ago, that of using all available resources to avoid the danger that the disease would recur after the operation, a clear paradigm shift is now underway – he comments Saverio Cinieri, president of the Italian Association of Medical Oncology (Aiom) —. Now we follow the philosophy of “less is more” (less more): we want to give our patients the least possible toxicity, we try to be as effective as possible with the bare minimum of therapies (and side effects). A change made possible by the many steps forward made by scientific research which has added, to chemotherapy, many new drugs targeting certain subtypes of breast cancer.
Avoid unnecessary chemotherapy
Surgery itself has gone from mastectomy (the removal of the whole breast) to much more limited and less invasive operations, whenever the neoplasm allows it. Learn to know the dozens of different types of breast cancer It was the first step in being able to distinguish the more aggressive ones, which in turn require heavy therapies also to avoid relapses or metastases, from the more indolent ones. The possibility of being able to prescribe genomic testswhich on the basis of the accurate classic definitions of pathological anatomy, allow us to avoid a part of adjuvant chemotherapies is, by far, one of the most important results achieved in recent years by science in the complex field of preventive chemotherapy – continues Cinieri, director of Medical Oncology and Breast Unit of the Perrino Hospital in Brindisi -. Even in metastatic disease, this change of vision has achieved unhoped-for effects only a few years ago. In disease with positive hormone receptors the need to start treatment using chemotherapy has fallen, but trying to reach the waiting time chronicity with molecules (often administered orally) that enable women to lead a normal life with cancer.
Include genomic tests in the Lea
Almost two years after the implementing decree of the Fund of 20 million euros for the purchase of genomic tests for breast cancerthese tests are finally available throughout Italy and are increasingly entering clinical practice, but their use needs to be encouraged more – he underlines Francesco Cognetti, president of the Confederation of Oncologists Cardiologists Hematologists (Foce) -. These are tests that identify patients who, treated with hormonal therapy alone, maintain themselves recurrence-free 10 years after diagnosis: this means that, after surgery, it is not necessary to resort to chemo. In short, they allow us a more appropriate therapeutic choice on the individual case. For this it would be appropriate include them in the Lea (essential levels of assistance)that is, in the list of services that the NHS is required to provide to all citizens, in order to increase the number of patients who receive it. Every year there are over 55,000 new cases of breast cancer in our country and, of these, at least 10,000 would be entitled to reimbursement for tests, which also allow for important economic benefits for healthcare, allowing savings on chemotherapy drugs and hospitalizations avoided.
Prolong survival in those with metastases
Many of the innovations presented at the Asco 2023 conference concerned hormone receptor-positive and HER2-negative breast cancer, the most frequent subtype of breast cancer. In particular, the TROPiCS-02 trial (phase three, the last before the definitive approval of a drug) recruited 543 patients with metastatic cancer previously treated with hormone therapy, cycline inhibitors and at least two lines of chemotherapy (many had already done four or more): some of the participants were then administered the drug sacituzumab govitecan, while the other group continued with chemotherapy. In patients who become resistant to hormone therapy, metastatic disease is difficult to manage and the results in terms of efficacy of currently available treatments are poor,” he explains Joseph Curigliano, director of the Division of development of new drugs for innovative therapies at the European Institute of Oncology in Milan —. From here the need for alternative options that can prolong survival and maintain quality of life, such as sacituzumab govitecan, which is already approved in Italy for triple-negative breast cancer. It’s about an anti-TROP2 conjugated antibody, an extremely innovative drug that exploits the ability of an antibody capable of targeting a specific target on tumor cells, bringing with it a powerful chemotherapy. This allows on the one hand a great therapeutic efficacy, on the other hand reduce the exposure-related toxicity of normal cells – continues Curigliano -. Long-term results from the TROPiCS-02 study show enduring benefit in delaying disease progression andlengthen overall survival compared to traditional chemotherapy (average 14.5 months versus 11.2). And it is reasonable to expect better results by anticipating the administration of sacituzumab, before so many lines of chemo.
Reduce the risk of relapse
Also presented in Chicago were updated data from the phase three ‘monarchE’ study indicating how with the addition of targeted therapy (abemaciclib) to standard hormonal care after surgery, the probability of recurrence and metastasis decreases in patients who have been diagnosed in the early stages, but with a dangerous neoplasm. The numbers that emerge from ‘monarchE’ are of extreme clinical relevance both for the extent of the benefit induced by abemaciclib and because this benefit concerns patients with cancer which, although in its initial stages, is at a higher risk of recurrence after surgery — he clarifies Lucia DelMastroprofessor of Oncology at the University of Genoa and director of the Medical Oncology Clinic of the San Martino Policlinico Hospital —. Trial involving 5,637 women and men with breast cancer with hormone-sensitive, node-positive breast cancer and a high risk of recurrence. The data presented at Asco concern the elderly population and indicate that the incidence of serious side effects is higher especially in women over 75 years of age and therefore there is a need for closer surveillance. In the end the role of circulating tumor DNA testing after pre-surgical chemotherapy appears to be increasingly important: The presence of this biomarker indicates, in fact, the presence of minimal residual disease and a high risk of relapse. Which leads us to believe that hormonal therapy after surgery could have limited efficacy and therefore we need to add other treatments concludes Del Mastro.
June 8, 2023 (change June 8, 2023 | 16:29)
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