Favorable locoregional control in clinically node-negative hormone-receptor positive breast cancer with low 21-gene recurrence scores: a single-institution study with 10-year follow-up.

BACKGROUND: Recent studies have shown a lower likelihood of locoregional recurrences in patients with a low 21-gene recurrence score (RS). In this single-institution study, we investigated whether there are any associations between different cutoff values of 21-gene RS, histopathological factors, and outcome in patients with long-term follow-up. METHODS: The study included 61 patients who had early-stage (I-II) clinically node-negative hormone receptor-positive and HER2-negative breast cancer and were tested with the 21-gene RS assay between February 2010 and February 2013. Demographic, clinicopathological, treatment, and outcome characteristics were analyzed. RESULTS: The median age was 48 years (range, 29-72 years). Patients with high histologic grade (HG), Ki-67 ≥ 25%, or Ki-67 ≥ 30% were more likely to have intermediate/high RS (≥ 18). Based on the 21-gene RS assay, only 19 patients (31%) received adjuvant chemotherapy. At a median follow-up of 112 months, 3 patients developed locoregional recurrences (4.9%), which were treated with endocrine therapy alone. Among patients treated with endocrine treatment alone (n = 42), the following clinicopathological characteristics were not found to be significantly associated with 10-year locoregional recurrence free survival (LRRFS): age < 40 years, age < 50 years, high histological or nuclear grade, high Ki-67-scores (≥ 15%, ≥ 20%, ≥ 25%, ≥ 30%), presence of lymphovascular invasion, luminal-A type, multifocality, lymph node positivity, tumor size more than 2 cm, RS ≥ 18, and RS > 11. However, patients with RS ≥ 16 had significantly poorer 10-year LRRFS compared to those with RS < 16 (75% vs. 100%, respectively; p = 0.039). CONCLUSIONS: The results suggest that patients with clinically node-negative disease and RS ≥ 16 are more likely to benefit from adjuvant chemotherapies. However, those with RS < 16 have an excellent outcome and local control in long-term follow-up with endocrine treatment alone.

The Impact of Everolimus and Radiation Therapy on Pulmonary Fibrosis.

Background and objectives: Everolimus (EVE) is a mammalian target of the rapamycin (mTOR) inhibitor that is widely used in cancer patients. Pulmonary toxicity, usually manifesting as interstitial pneumonitis, is a serious adverse effect of this drug. Radiation therapy, which is often administered in conjunction with chemotherapy for synergistic effects, also causes pulmonary fibrosis. In view of pulmonary damage development in these two forms of cancer treatment, we have examined the effect of EVE administration individually, in combination with radiation given in varying sequences, and its relation to the extent of pulmonary damage. Materials and Methods: We performed an experimental study in albino rats, which were randomized into five groups: (1) control group, (2) EVE alone, (3) EVE 22 h after radiation, (4) EVE 2 h after irradiation, and (5) only radiation. Sixteen weeks after thoracic irradiation, rat lung tissue samples were examined under light microscopy, and the extent of pulmonary damage was estimated. After this, we calculated median fibrosis scores in each group. Results: The highest fibrosis score was noted in Group 4. Among the five groups, the control group had a significantly lower median fibrosis score compared to the others. When the median fibrosis score of the group that received concurrent EVE with radiation therapy (RT) (Group 4) was compared with that of the control group, the difference was statistically significant (p = 0.0022). However, no significant differences were achieved among the study groups that received EVE only or RT only, whether concurrently or sequentially (p > 0.05). Conclusion: EVE is an effective treatment option for the management of several malignancies and is often combined with other therapies, such as radiation, for a more efficient response. However, an increased risk of pulmonary fibrosis should also be anticipated when these two modalities are combined, as they both can cause pulmonary damage, especially when administered concurrently.

DNA repair and apoptosis: Roles in radiotherapy-related acute reactions in breast cancer patients.

Normal tissue reactions are therapy limiting factor for the effectiveness of the radiotherapy in cancer patients. DNA repair and apoptosis are estimated to be critical players of adverse effects in response to radiotherapy. Our aim was to define the association of DNA repair (ERCC1 and XPC) and apoptotic (BCL2, CASP3 and NFKB1) gene expression, DNA damage levels, apoptosis changes and DNA repair gene variations with the risk of acute side effects in breast cancer patients. The study included 100 women with newly diagnosed breast cancer; an experimental case group (n=50) with acute side effects and the control group (n=50) without side effects. Gene expression was analyzed by reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR). Micronucleus (MN) and 8-hydroxy-2'-deoxyguanosine (8-OHdG) assays were performed to compare the DNA damage levels. Apoptosis was examined by TDT-mediated dUTP-biotin nick end-labeling (TUNEL) staining. ERCC1 rs3212986 and XPC rs3731055 polymorphisms were genotyped by real-time PCR technique. No significantly correlation of DNA repair and apoptosis gene expression and DNA damage levels with acute side effects in response to radiotherapy. Also, there was no association between apoptosis levels and acute effects. ERCC1 rs3212986 CC genotype showed a protective effect against radiotherapy-induced acute reactions (p<0.001; OR: 0.21; 95% CI= 0.08-0.52). Our results suggest that apoptosis and DNA damage levels are not associated with acute radiosensitivity. DNA repair may affect the risk of acute reactions. Further studies are needed to validate the current findings.

The satisfaction of patients with breast cancer undergone immediate reconstruction with implant and the effect of radiotherapy.

AIM OF THE STUDY: Postmastectomy reconstructive surgery for cosmetic satisfaction of patients is rapidly increasing. Postoperative complications such as infection, capsular contracture, implant loss are more common in patients who receive adjuvant radiotherapy (RT) than those who do not. Satisfaction levels in patients is still a controversial issue. Therefore, we wanted to investigate our patient population for the effects of RT and planned a study evaluating the satisfaction rates of our patients who received implants. MATERIAL AND METHODS: Seventy five breast cancer patients who went through mastectomy and went through reconstruction using expanders or silicone implants were surveyed. Complication and cosmetic satisfaction rates were separately compared between irradiated and nonirradiated implants. Responses of 46 patients who answered the survey were analyzed using χ2 test and Mann Whitney U test. p < 0.05 was considered statistically significant. RESULTS: Thirty-one of the patients received adjuvant RT and 15 did not receive RT (NRT). There was no difference between the RT and NRT groups in the terms of touch, size, shape of silicones, pain and satisfaction level in look of clothing. Only satisfaction in symmetry was significantly lower in the RT group than in the NRT group (p = 0.02). Additionally, patients receiving chemotherapy were less satisfied with silicone size than those who did not (p = 0.02). CONCLUSION: We did not find negative effects, other than symmetry, of adjuvant radiotherapy in breast cancer patients who underwent reconstructive surgery in terms of cosmetic satisfaction.

Optimisation of the continuum of supportive and palliative care for patients with breast cancer in low-income and middle-income countries: executive summary of the Breast Health Global Initiative, 2014.

Supportive care and palliative care are now recognised as critical components of global cancer control programmes. Many aspects of supportive and palliative care services are already available in some low-income and middle-income countries. Full integration of supportive and palliative care into breast cancer programmes requires a systematic, resource-stratified approach. The Breast Health Global Initiative convened three expert panels to develop resource allocation recommendations for supportive and palliative care programmes in low-income and middle-income countries. Each panel focused on a specific phase of breast cancer care: during treatment, after treatment with curative intent (survivorship), and after diagnosis with metastatic disease. The panel consensus statements were published in October, 2013. This Executive Summary combines the three panels' recommendations into a single comprehensive document covering breast cancer care from diagnosis through curative treatment into survivorship, and metastatic disease and end-of-life care. The recommendations cover physical symptom management, pain management, monitoring and documentation, psychosocial and spiritual aspects of care, health professional education, and patient, family, and caregiver education.

A cross-sectional survey of the diagnosis and management of bone metastasis in breast cancer patients in Turkey.

PURPOSE: This study aimed to report the practice of managing breast cancer with bone metastasis in Turkey and to determine the adherence to the British Association of Surgical Oncology (BASO) guidelines. METHODS: This multicenter, cross-sectional epidemiological survey was conducted in 38 centers across Turkey. Data from 1,026 breast cancer patients with bone metastases (mean age 54.0 ± 11.9 years) were analyzed. RESULTS: Over 30 % of patients had a diagnosis of metastatic breast cancer (stage IV) at the time of primary diagnosis. The imaging modalities used for diagnosing bone metastases were bone scintigraphy (57.8 %), radiography (22.8 %), and bone survey (4.4 %). Tumor markers were detected in 94.9 %, and markers of bone metabolism were measured in 90.4 % of patients. A total of 3.5 % of patients underwent surgery for bone metastasis, 26.4 % underwent palliative chemotherapy (most commonly docetaxel + capecitabine), and 56.5 % endured radiotherapy. Most patients (96 %) also received bisphosphonate. Radiography, bone scintigraphy, and CT were the main imaging tools used for postoperative follow-up of bone metastasis. Our results were >95 % in line with the BASO guidelines for the management of bone metastasis, except that interventional procedures, such as biopsy, were applied less frequently in our survey. CONCLUSIONS: The diagnosis and management practices of breast cancer with bone metastasis in Turkey were generally compatible with international guidelines. However, the awareness and knowledge of physicians on the current guidelines should be increased, and equipment for the appropriate interventional procedures should be provided in every clinic to obtain optimal and standard management of bone metastases.

New Approaches in Breast Cancer Radiotherapy.

Breast cancer stands as the most prevalent malignancy, necessitating a well-established approach to its management due to its sustained prevalence over decades. The implementation of intensive treatments, combining various modalities, has yielded excellent survival outcomes. Consequently, the optimization of quality of life and the mitigation of long-term side effects emerge as critical considerations for clinicians. As a result, discussions regarding treatment de-intensification strategies have been initiated for all treatment modalities, including surgery, radiotherapy (RT), and chemotherapy. RT plays a crucial role in adjuvant therapy. The efficacy of RT in disease control and overall survival across all stages of breast cancer has been demonstrated in numerous clinical trials and meta-analyses utilizing extensive datasets. However, advancements in genetic tumor profiling and improved identification of disease subgroups have prompted a reevaluation of RT omission in low-risk groups as a strategy for treatment de-intensification. Conversely, technological improvements and shortened total treatment times with hypofractionation make RT a secure and feasible option for enhancing local control and survival with minimal impact on the quality of life.

Male breast cancers behave differently in elderly patients.

OBJECTIVE: The aim of this study was to evaluate tumor characteristics, management and survival in elderly male breast cancer patients in comparison with younger men. METHODS: We reviewed medical records of 99 male breast cancer patients between 1972 and 2011. The median age of the patients was 64.5 years. Patient characteristics including clinicopathologic factors, treatment modalities, survival and prognostic factors were evaluated. Patients were subdivided into two groups according to their age (young, <65 years; old, ≥ 65 years) and compared based on these factors. RESULTS: Elderly male breast cancer patients had larger tumors in more advanced stages at the time of diagnosis compared with younger patients. In spite of the larger tumors at presentation, older patients had tumors with more favorable biological characteristics, such as higher ratio of estrogen and progesterone receptor expression. Ten-year cancer-specific survival for older patients was 49.2% compared with 55.8% in younger men (P = 0.8). Prognostic factors influencing overall survival in univariate analysis were: the presence of metastatic axillary lymph nodes (P = 0.0001), T stage (P = 0.001) and age ≥ 65 years. Multivariate analysis indicated T stage (P = 0.008) and N stage (P = 0.038) as the significant negative prognostic factors for overall survival. Although surgery, radiotherapy and hormone therapy were equally utilized in old and young patients, old patients were less likely to receive adjuvant chemotherapy. CONCLUSIONS: Our study demonstrated the differences in the clinical and biological characteristics of male breast cancer according to the age of the patients.

Comparison of mammography and ultrasound findings in the follow-up of patients with breast cancer treated with segmental mastectomy followed by intraoperative electron radiotherapy versus external whole breast radiotherapy

PURPOSE: This study aims to describe imaging findings in patients treated with intraoperative electron radiotherapy and compare them with those detected in patients treated with external whole breast radiotherapy (WBRT). METHODS: The study population consisted of 25 patients who received intraoperative radiotherapy [IORT (21 Gy)] as single-dose radiotherapy and a control group of 25 patients who received WBRT at the same institution. Mammography and ultrasound (US) findings were divided into three groups: minor, intermediate, and advanced. On mammography, mass lesions were considered advanced, and asymmetries or architectural distortions were considered intermediate. Oil cysts, linear scars, and the increase in parenchymal density were considered minor findings. On US, irregular non-mass lesions were considered advanced, and circumscribed hypoechoic lesions or planar irregular scars with shadowing were considered intermediate. Oil cysts, fluid collections, or linear scars were considered minor findings. RESULTS: On mammography, skin thickening (P = 0.001), edema (P < 0.001), increased parenchymal density (P < 0.001), dystrophic calcifications (P = 0.045), and scar/distortion (P = 0.005) were significantly more common in the WBRT group. On US, irregular non-mass lesions, which made interpretation considerably difficult, were significantly more common in the IORT group (P = 0.004). Dominant US findings were fluid collections and postoperative linear or planar scars in the WBRT group. Minor findings were more common in low-density breasts, and major findings (intermediate and advanced) were more common in high-density breasts on both mammographies (P = 0.011) and US (P = 0.027) in the IORT group. CONCLUSION: Ill-defined non-mass lesions detected on US in the IORT group have not been defined previously. Radiologists should be aware of these lesions because they can be confusing, especially in early follow-up studies. This study has found that minor findings are seen more frequently in low-density breasts, while major findings are more common in high-density breasts in the IORT group. This has not been reported before, and further studies with more cases are needed to verify these results.

Optimizing the Personalized Care for the Management of Rectal Cancer: A Consensus Statement.

Colorectal cancer is the third most common cancer in Turkey. The current guidelines do not provide sufficient information to cover all aspects of the management of rectal cancer. Although treatment has been standardized in terms of the basic principles of neoadjuvant, surgical, and adjuvant therapy, uncertainties in the management of rectal cancer may lead to significant differences in clinical practice. In order to clarify these uncertainties, a consensus program was constructed with the participation of the physicians from the Acibadem Mehmet Ali Aydinlar and Koç Universities. This program included the physicians from the departments of general surgery, gastroenterology, pathology, radiology, nuclear medicine, medical oncology, radiation oncology, and medical genetics. The gray zones in the management of rectal cancer were determined by reviewing the evidence-based data and current guidelines before the meeting. Topics to be discussed consisted of diagnosis, staging, surgical treatment for the primary disease, use of neoadjuvant and adjuvant treatment, management of recurrent disease, screening, follow-up, and genetic counseling. All those topics were discussed under supervision of a presenter and a chair with active participation of related physicians. The consensus text was structured by centralizing the decisions based on the existing data.

Were We Able to Reduce Cardiac Doses in Breast Cancer Radiotherapy Over Time?

OBJECTIVE: In this study, we aimed to review the heart and left coronary artery doses over the years in patients who received breast cancer radiotherapy (RT). MATERIALS AND METHODS: A total of 436 breast cancer patients of 2 RT centers treated between the years 2010 and 2018 were included. The mean heart doses (HeartDmean-HDM) and left coronary artery mean doses (LDM) were analyzed using nonparametric tests. The conventional RT (CRT) was 50 Gy/2 Gy in 5 weeks, and the hypofractionated RT (HRT) was 40.05 Gy/2.67 Gy in 3 weeks. Boost was applied as 10-16 Gy/2 Gy for CRT and 10 Gy/2.5 Gy for HRT. An equivalent conventional total dose of 2 Gy/fraction (EQD2) was taken into account for HRT. RESULTS: HDM was 107±104 cGy, and LDM was 288±209 cGy for the entire group. HDM was significantly lower in patients with breast-conserving surgery (99±94 cGy) than that in those with mastectomy (128±124 cGy) (p<0.001). Field-in-field intensity-modulated RT technique significantly reduced the doses compared to volumetric applications (104±95 cGy vs 141±38 cGy; p = 0.002). HDM was significantly increased with lymphatic RT (132±58 cGy vs 112±115 cGy; p<0.001). The addition of internal mammary volumes significantly increased HDM (p<0.001). No significant effect of boost was observed (p = 0.96). For both CRT and HRT regimens, HDM values were significantly lower after the year 2014 (right side p<0.001, left side p = 0.01). In the left side CRT, HDM was 1.74 Gy before 2014 and 1.3 Gy after 2014 and 1.0 and 1.19 Gy, respectively, for the right side. CONCLUSION: All efforts to reduce the cardiac doses will likely reduce long-term side effects.

Temporary Implant Irradiation: Survey of Turkish Society of Radiation Oncology Breast Cancer Study Group.

OBJECTIVE: To understand the clinical approach of radiation oncologists during the treatment of patients with breast reconstruction. MATERIALS AND METHODS: A questionnaire survey was emailed to 105 active members of the Turkish Radiation Oncology Society, the Breast Cancer Study Group. The factors associated with radiation oncologists and their current practice was identified. RESULTS: Fifty radiation oncologists (47.6%) responded, and most of the responders (83%) were physicians who treated >50 new breast cancer patients annually. The majority of the physicians worked in academic hospitals and had more than 15 years of work experience. The early reconstruction rate was noted to be low among patients with mastectomy (<10% of the mastectomy patients) (p<0.05). Early implant irradiation with temporary tissue expander was noted to be a more common procedure. The majority of the respondents (68%) preferred to irradiate an inflated implant (20% total, 80% partial). In addition, 22% of the physicians declared that they routinely used bolus and that 60% of them used it only for patients at a high risk of local recurrence factors. CONCLUSION: It can thus be concluded that variations exist between experienced radiation oncologists and others. Hypofractionation is not yet commonly practiced for patients with reconstruction in Turkey. A concrete consensus can be helpful to create a homogeneity in treatment decisions and practical applications.

The use of bolus in postmastectomy radiation therapy for breast cancer: A systematic review.

PURPOSE: Post mastectomy radiation therapy (PMRT) reduces locoregional recurrence (LRR) and breast cancer mortality for selected patients. Bolus overcomes the skin-sparing effect of external-beam radiotherapy, ensuring adequate dose to superficial regions at risk of local recurrence (LR). This systematic review summarizes the current evidence regarding the impact of bolus on LR and acute toxicity in the setting of PMRT. RESULTS: 27 studies were included. The use of bolus led to higher rates of acute grade 3 radiation dermatitis (pooled rates of 9.6% with bolus vs. 1.2% without). Pooled crude LR rates from thirteen studies (n = 3756) were similar with (3.5%) and without (3.6%) bolus. CONCLUSIONS: Bolus may be indicated in cases with a high risk of LR in the skin, but seems not to be necessary for all patients. Further work is needed to define the role of bolus in PMRT.

A Delphi study and International Consensus Recommendations: The use of bolus in the setting of postmastectomy radiation therapy for early breast cancer.

Bolus serves as a tissue equivalent material that shifts the 95-100% isodose line towards the skin and subcutaneous tissue. The need for bolus for all breast cancer patients planned for postmastectomy radiation therapy (PMRT) has been questioned. The work was initiated by the faculty of the European SocieTy for Radiotherapy & Oncology (ESTRO) breast cancer courses and represents a multidisciplinary international breast cancer expert collaboration to optimize PMRT. Due to the lack of randomised trials evaluating the benefits of bolus, we designed a stepwise project to evaluate the existing evidence about the use of bolus in the setting of PMRT to achieve an international consensus for the indications of bolus in PMRT, based on the Delphi method.

Optimal sequence of implied modalities in the adjuvant setting of breast cancer treatment: an update on issues to consider.

The adjuvant setting of early breast cancer treatment is an evolving field where different modalities must be combined to improve outcomes; moreover, quality of life of breast cancer survivors emerges as a new important parameter to consider, thus implying a better understanding of toxicities of these modalities. We have conducted a review focusing on the latest literature of the past 3 years, trying to evaluate the existing data on the maximum acceptable delay of radiotherapy when given as sole adjuvant treatment after surgery and the optimal sequence of all these modalities with respect to each other. It becomes evident radiotherapy should be given as soon as possible and within a time frame of 6-20 weeks. Chemotherapy is given before radiotherapy and hormone therapy. However, radiotherapy should be started within 7 months after surgery in these cases. Hormone therapy with tamoxifen might be given safely concomitantly or sequentially with radiotherapy although solid data are still lacking. The concurrent administration of letrozole and radiotherapy seems to be safe, whereas data on trastuzumab can imply only that it is safe to use concurrently with radiotherapy. Randomized comparisons of hormone therapy and trastuzumab administration with radiotherapy need to be performed.

The investigation of fetal doses in mantle field irradiation.

To determine clinically the fetal dose from irradiation of Hodgkin's disease during pregnancy and to quantify the components of fetal dose using phantom measurements. The fetal dose was measured with phantom measurements using thermoluminescent dosemeters (TLDs). Phantom measurements were performed by simulating the treatment conditions on an anthropomorphic phantom. TLDs were placed on the phantom 41, 44, 46.5 and 49.5 cm from the centre of the treatment field. Two TLDs were placed on the surface of the phantom. The estimated total dose to all the TLDs ranged from 8.8 to 13.2 cGy for treatment with (60)Co and from 8.2 to 11.8 cGy for 4 MV photons. It was concluded that the doses in different sections were evaluated to investigate dose changes in different points and depths of fetal tissues in phantom. Precise planning and the use of supplemental fetal shielding may help reduce fetal exposure.

Dosimetric evaluation of right coronary artery in radiotherapy for breast cancer.

Comparison with control groups of untreated patients suggests that right-breast-cancer patients who receive radiotherapy have a higher rate of heart disease. Dose constraint for heart has been established to minimize radiotherapy-induced cardiotoxicity during left breast cancer treatment. Additionally, it is suggested to minimize the dosage on left anterior descending (LAD) artery. Right coronary artery (RCA), is the second largest artery, after left main coronary artery, supplying the heart. A dose evaluation study is not present for RCA; the proximal part of which is included in the irradiation field during breast cancer treatment of right breast. To investigate the presence of a correlation, doses resulting from right and left breast radiotherapy on proximal RCA (pRCA), LAD, and heart are evaluated in this study. Forty breast cancer patients who went under breast-conserving surgery are the subject of this study. Four groups were established; right breast, right breast and internal mammary (IM), left breast and left breast, and IM. pRCA, LAD, and heart volumes were contoured for each group on the planning tomographies. Resultant doses of tangential fields planning on these volumes were compared using dose-volume histograms. Mean and maximum doses of pRCA were statistically compared between groups. The highest mean and maximum point doses (192 to 284 cGy) were found in the right breast + IM group (p < 0.05). The mean and maximum doses only in the right breast and left breast + IM group did not differ statistically. However, the mean and maximum pRCA doses in these 2 groups were higher than only the left breast group (p < 0.05). pRCA receives high doses during radiotherapy of right and left breast especially if IM is included. This may predispose to coronary artery disease.

Breast radiation therapy guideline implementation in low- and middle-income countries.

Radiation therapy plays a critical role in the management of breast cancer and often is unavailable to patients in low- and middle-income countries (LMCs). There is a need to provide appropriate equipment and to improve the techniques of administration, quality assurance, and use of resources for radiation therapy in LMCs. Although the linear accelerator is the preferred equipment, telecobalt machines may be considered as an acceptable alternative in LMCs. Applying safe and effective treatment also requires well trained staff, support systems, geographic accessibility, and the initiation and completion of treatment without undue delay. In early-stage breast cancer, standard treatment includes the irradiation of the entire breast with an additional boost to the tumor site and should be delivered after treatment planning with at least 2-dimensional imaging. Although postmastectomy radiation therapy (PMRT) has demonstrated local control and overall survival advantages in all patients with axillary lymph node metastases, preference in limited resource settings could be reserved for patients who have >or=4 positive lymph nodes. The long-term risks of cardiac morbidity and mortality require special attention to the volume of heart and lungs exposed. Alternative treatment schedules like hypofractionated radiation and partial breast irradiation currently are investigational. Radiation therapy is an integral component for patients with locally advanced breast cancer after initial systemic treatment and surgery. For patients with distant metastases, radiation is an effective tool for palliation, especially for bone, brain, and soft tissue metastases. The implementation of quality-assurance programs applied to equipment, the planning process, and radiation treatment delivery must be instituted in all radiation therapy centers.

Guideline implementation for breast healthcare in low- and middle-income countries: treatment resource allocation.

A key determinant of breast cancer outcome is the degree to which newly diagnosed cancers are treated correctly in a timely fashion. Available resources must be applied in a rational manner to optimize population-based outcomes. A multidisciplinary international panel of experts addressed the implementation of treatment guidelines and developed process checklists for breast surgery, radiation treatment, and systemic therapy. The needed resources for stage I, stage II, locally advanced, and metastatic breast cancer were outlined, and process metrics were developed. The ability to perform modified radical mastectomy is the mainstay of locoregional treatment at the basic level of breast healthcare. Radiation therapy allows for consideration of breast-conserving therapy, postmastectomy chest wall irradiation, and palliation of painful or symptomatic metastases. Systemic therapy with cytotoxic chemotherapy is effective in the treatment of all biologic subtypes of breast cancer, but its provision is resource intensive. Although endocrine therapy requires few specialized resources, it requires knowledge of hormone receptor status. Targeted therapy against human epidermal growth factor receptor 2 (anti-HER-2) is very effective in tumors that overexpress HER-2/neu receptors, but cost largely prevents its use in resource-limited environments. Incremental allocation of resources can help address economic disparities and ensure equity in access to care. Checklists and allocation tables can support the objective of offering optimal care for all patients. The use of process metrics can facilitate the development of multidisciplinary, integrated, fiscally responsible, continuously improving, and flexible approaches to the global enhancement of breast cancer treatment.

Investigation of genotoxicity risk and DNA repair capacity in breast cancer patients using anastrozole.

OBJECTIVE: Breast cancer is the most common cancer in women worldwide and the incidence increases in postmenopausal women. Anastrozole is a non-steroidal (type II), third-generation aromatase inhibitor (AI) that is used in the treatment of postmenopausal estrogen-related breast cancer. Several studies have been conducted to assess the efficacy, safety, and superiority of AIs to tamoxifen; however, a literature search did not reveal a study that investigated the genotoxic potential of AIs. The aim of this study was to investigate the possible DNA damage risk profile and individual DNA repair capacity of patients using anastrozole with the modified alkaline comet assay in order to contribute to public health and health economics. METHODS: Women diagnosed with breast cancer after menopause comprised the study group. Six patients who had taken anastrozole for at least 6 months were retrospectively enrolled, and 12 patients who had not yet received treatment were prospectively enrolled as a control group. Peripheral blood lymphocytes were used to measure oxidized DNA damage using formamidopyrimidine DNA-glycosylase (FPG) and endonuclease III (endo III) in a modified comet assay. Individual DNA repair capacity was evaluated with the comet assay after a hydrogen peroxide (H2O2) challenge to examine the difference in DNA damage susceptibility. RESULTS: Analysis of DNA damage, oxidative base damage, susceptibility to DNA damage, and repair capacity revealed no significant difference between the control group and the patients taking anastrozole (p>0.05). Susceptibility to H2O2 damage was observed to increase with age (p<0.05). CONCLUSION: According to the results obtained in this study, anastrozole did not contribute to oxidative DNA damage. An H2O2 challenge with the comet assay is useful to evaluate circumstances of increased vulnerability to damage, such as aging and cancer.