Análisis y recomendaciones para la mejora de la gestión clínica y la atención del cáncer de mama metastásico en España / Analysis and recommendations for improved clinical management and care of metastatic breast cancer in Spain

El cáncer de mama metastásico (CMM) constituye la primera causa de muerte por cáncer entre las mujeres y plantea importantes retos en la práctica clínica y en la convivencia con la enfermedad para pacientes y familiares. Con la participación de un amplio panel de oncólogos médicos y representantes de pacientes, en este proyecto se analizaron los recursos (herramientas de planificación, registros de cáncer), proceso asistencial (diagnóstico, tratamiento, cuidados paliativos) y procesos transversales (atención psicosocial, hábitos de vida saludables, rol de las asociaciones de pacientes) en el abordaje del CMM en el contexto sanitario español. El trabajo realizado permitió identificar una serie de áreas de mejora y proponer 42 recomendaciones orientadas a mejorar la calidad asistencial y la atención de los pacientes con CMM y sus cuidadores organizadas en las siguientes áreas de acción: registros de cáncer, coordinación entre niveles asistenciales, diagnóstico de la metástasis, comunicación y habilidades interpersonales, accesibilidad a fármacos, ensayos clínicos, el papel de la enfermería en el CMM, cuidados paliativos, atención psicosocial y promoción de estilos de vida saludables. Estas recomendaciones, elaboradas desde una perspectiva integral y centradas en las características del entorno sanitario en España, ofrecen un punto de partida para la mejora de la calidad asistencial y pueden ser de gran valor en otros entornos sanitarios que se enfrenten a las mismas necesidades en el abordaje del CMM. (AU)

Metastatic breast cancer (MBC) is the first cause of cancer-related mortality among women and poses major challenges in clinical practice and for persons with the disease and their families. With the collaboration of a wide panel of medical oncologists and patient representatives, this project analysed the resources (planning tools, cancer registries), healthcare processes (diagnosis, treatment, palliative care) and related processes (psychosocial care, healthy lifestyles, role of patient associations) in the approach to MBC in the Spanish healthcare setting. The work carried out allowed identification a series of areas for improvement and a proposal for 42 recommendations aimed at improving healthcare quality and the care of patients with MBC and their carers organized in the following areas: cancer registries, liaison between healthcare levels, diagnosis of metastasis, communication and interpersonal skills, drug access, clinical trials, the role of nurses in MBC, palliative care, psychosocial care, and promotion of healthy lifestyles. These recommendations, drafted from an integrated perspective and based on the characteristics of the Spanish healthcare setting, provide a springboard for healthcare improvement and could be of strong value to other healthcare settings facing the same challenges in the approach to MBC. (AU)

Predicción de riesgo de cáncer de mama en mujeres sanas de población española basado en el estudio de variantes genéticas / Prediction of cancer risk based on study of genetic variants in healthy women in the Spanish population

Objetivo: Estratificación de la población general con base en las variantes genotípicas para seleccionar a aquellas mujeres de alto riesgo a desarrollar un cáncer de mama que puedan ser candidatas a un seguimiento individualizado. Material y métodos: Se ha realizado un estudio caso-control en 856 mujeres con cáncer de mama y 839 mujeres controles de la población general pareadas por edad, analizando la asociación entre el riesgo a desarrollar cáncer de mama y un grupo de variantes basado en 76 polimorfismos de un cambio de base (SNP) de susceptibilidad. Resultados: Se han establecido 2curvas de casos y controles con base en las odds ratio (OR) genotípicas que diferencian las 2poblaciones con significación estadística (p = 2,293×10-15). Asimismo, se ha estratificado la población de casos y controles e identificado un 14% de la población que se encontraría en el grupo de alto riesgo con una OR > 2 (> 25% probabilidades de desarrollar un cáncer de mama). Este grupo sería candidato a un seguimiento individualizado. Conclusiones: El Polygenic Risk Score es un predictor del riesgo del cáncer de mama independiente que puede ayudar a seleccionar mujeres con alto riesgo para establecer medidas de seguimiento y tratamiento individualizado en función del riesgo genético

Objective: To stratify the general population based on genotypic variants in order to select women at high risk of breast cancer who could be candidates for individualized follow-up. Material and methods: We performed a case-control study in 856 women with breast cancer and 839 aged-matched control women from the general population. We analysed the association between the risk of developing breast cancer and a group of variants based on 76 susceptibility single nucleotide polymorphisms. Results: Two case-control curves were established based on genotypic odds ratios (OR) that differentiated the 2populations with statistical significance (P=2.293×10-15). Stratification of the case-control population showed that 14% of the population would be at high risk, with an OR>2 (> 25% probability of developing breast cancer). Persons in this group would be candidates for individualized follow-up. Conclusions: The Polygenic Risk Score is an independent predictor of breast cancer risk that may help to select women at high risk, with a view to establishing individualised follow-up and treatment according to genetic risk

Nuevos retos en el tratamiento y la investigación del cáncer de mama / New Challenges in the treatment and research of breast cancer

La terapia contra el cáncer ha experimentado importantes avances que se han producido con una celeridad inusitada. El arsenal terapéutico se ha intensificado en eficacia contando con los citostáticos o lo que se conoce comúnmente como ‘quimioterapia’, fármacos de diferentes mecanismos de acción que inducen la apoptosis o muerte celular pero de su escasa especificidad para atacar exclusivamente la célula tumoral, afectando también a células sanas. Recientemente aparecen las nuevas terapias dirigidas contra un objetivo concreto, una proteína o un receptor de membrana ubicada en la célula tumoral,. Las primeras terapias antidiana introducidas fueron anticuerpos monoclonales de administración intravenosa, sin embargo en los últimos años hemos asistido a un verdadero ‘boom’ con el desarrollo de una nueva familia de terapias dirigidas orales, llamadas inhibidores de tirosinquinasa. Estas novedades en apoyo a la cirugía y la oncorradiología con sus avances espectaculares de los últimos años han contribuido de forma muy importante a una mejora del control de la enfermedad o en la calidad de vida de los pacientes

Cancer therapy has undergone major developments that have occurred with unusual speed. The therapeutic arsenal has intensified in effectively having cytostatic or what is commonly known as ‘chemo’ drugs of different mechanisms of action that induce apoptosis or cell death but its poor specificity to attack only the tumor cell, affecting also healthy cells. New therapies directed against a specific target, a protein or a membrane receptor located on the tumor cell recently shown, The first antidiana therapies were introduced intravenously administered monoclonal antibodies, however in recent years have witnessed a real ‘boom’ with the development of a new family of oral targeted therapies, called tyrosine kinase inhibitors. These developments in support of surgery and oncoradiología with its spectacular advances in recent years have contributed very significantly to improved disease control or quality of life of patients

An overview of letrozole in postmenopausal women with hormone-responsive breast cancer.

Third-generation aromatase inhibitors (AIs) have proven to be superior to tamoxifen in terms of time to disease progression in patients with hormone receptor (HR) positive (HR+) status and, nowadays, are used in the adjuvant and neoadjuvant settings, and first-line therapy for advanced breast cancer. Letrozole is a third generation AI, as are anastrozole and exemestane. In the past, clinical studies had demonstrated that letrozole was effective as a second-line treatment of metastatic breast cancer. In this paper, pharmacokinetic and pharmacodynamic properties of letrozole are reviewed along with its activity in preclinical and clinical settings. Additionally, the results of important clinical trials such as Breast International Group (BIG) 1-98, which tested the optimal initial adjuvant endocrine treatment and the sequential therapy with letrozole and tamoxifen, MA-17 that evaluates the benefits of extended adjuvant therapy, and other important studies in advanced and neoadjuvant disease, are reviewed. Safety comparisons of treatments are also addressed. Interestingly, about 50% of human epidermal growth factor receptor 2-positive (HER2+) breast cancers are HR+. However, HER2 positivity is a marker of antiestrogen treatment resistance. Because of this, a dual treatment is a logical approach when both receptors are overexpressed. The combination of lapatinib and letrozole leads to a significant improvement in the overall disease outcome. Also, the combination of everolimus plus letrozole has been tested in this setting. In fact, the coadministration of both agents seems to increase the efficacy of letrozole in newly-diagnosed HR+ patients. Once resistance to sequential trastuzumab and AI as monotherapy has been found, trastuzumab and letrozole combined in HR+ and HER2+ patients with advanced breast cancer can overcome resistance to both drugs administered as single agents, according to recently reported results.

Spanish Society of Medical Oncology consensus for the use of haematopoietic colony-stimulating factors in cancer patients.

Neutropenia is a common complication of cancer chemotherapy. Colony-stimulating factors (CSF) may be used to avoid neutropenia-associated complications. The Spanish Society of Medical Oncology (SEOM) recently constituted a working group to review the main issues concerning the use of CSF and carried out a consensus process about the use of CSF in cancer patients, held in Madrid on 26 May 2006. The group concluded the following recommendations: prophylactic use of CSF is recommended when a rate of febrile neutropenia (FN) higher than 20% is expected without the use of CSF or when additional risk factors for neutropenia exist; therapeutic use of CSF is recommended in order to treat FN episodes but not to treat afebrile neutropenic episodes. In addition, the use of CSF is considered effective when used to mobilise stem cells before high-dose chemotherapy and when used for chemotherapy schedule optimisation in dose-dense and in dose-intense regimens.