Tailoring neo/adjuvant systemic therapy in breast cancer: "The advent of a personalized approach"-The Breast-Gynecological and Immuno-Oncology International Cancer Conference (BGICC) consensus and recommendations.

BACKGROUND: The management of early breast cancer (BC) has witnessed an uprise in the use of neoadjuvant therapy and a remarkable reshaping of the systemic therapy postneoadjuvant treatment in the last few years, with the evolution of many controversial clinical situations that require consensus. METHODS: During the 14th Breast-Gynecological and Immuno-Oncology International Cancer Conference held in Egypt in 2022, a panel of 44 BC experts from 13 countries voted on statements concerning debatable challenges in the neo/adjuvant treatment setting. The recommendations were subsequently updated based on the most recent data emerging. A modified Delphi approach was used to develop this consensus. A consensus was achieved when ≥75% of voters selected an answer. RESULTS AND CONCLUSIONS: The consensus recommendations addressed different escalation and de-escalation strategies in the setting of neoadjuvant therapy for early BC. The recommendations recapitulate the available clinical evidence and expert opinion to individualize patient management and optimize therapy outcomes. Consensus was reached in 63% of the statements (52/83), and the rationale behind each statement was clarified.

Baseline [18F]FDG PET/CT and MRI first-order breast tumor features do not improve pathological complete response prediction to neoadjuvant chemotherapy.

PURPOSE: To verify the ability of pretreatment [18F]FDG PET/CT and T1-weighed dynamic contrast-enhanced MRI to predict pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) in breast cancer (BC) patients. METHODS: This retrospective study includes patients with BC of no special type submitted to baseline [18F]FDG PET/CT, NAC and surgery. [18F]FDG PET-based features reflecting intensity and heterogeneity of tracer uptake were extracted from the primary BC and suspicious axillary lymph nodes (ALN), for comparative analysis related to NAC response (pCR vs. non-pCR). Multivariate logistic regression was performed for response prediction combining the breast tumor-extracted PET-based features and clinicopathological features. A subanalysis was performed in a patients' subsample by adding breast tumor-extracted first-order MRI-based features to the multivariate logistic regression. RESULTS: A total of 170 tumors from 168 patients were included. pCR was observed in 60/170 tumors (20/107 luminal B-like, 25/45 triple-negative and 15/18 HER2-enriched surrogate molecular subtypes). Higher intensity and higher heterogeneity of [18F]FDG uptake in the primary BC were associated with NAC response in HER2-negative tumors (immunohistochemistry score 0, 1 + or 2 + non-amplified by in situ hybridization). Also, higher intensity of tracer uptake was observed in ALN in the pCR group among HER2-negative tumors. No [18F]FDG PET-based features were associated with pCR in the other subgroup analyses. A subsample of 103 tumors was also submitted to extraction of MRI-based features. When combined with clinicopathological features, neither [18F]FDG PET nor MRI-based features had additional value for pCR prediction. The only significant predictors were estrogen receptor status, HER2 expression and grade. CONCLUSION: Pretreatment [18F]FDG PET-based features from primary BC and ALN are not associated with response to NAC, except in HER2-negative tumors. As compared with pathological features, no breast tumor-extracted PET or MRI-based feature improved response prediction.

Joint EANM-SNMMI guideline on the role of 2-[18F]FDG PET/CT in no special type breast cancer : (endorsed by the ACR, ESSO, ESTRO, EUSOBI/ESR, and EUSOMA).

INTRODUCTION: There is much literature about the role of 2-[18F]FDG PET/CT in patients with breast cancer (BC). However, there exists no international guideline with involvement of the nuclear medicine societies about this subject. PURPOSE: To provide an organized, international, state-of-the-art, and multidisciplinary guideline, led by experts of two nuclear medicine societies (EANM and SNMMI) and representation of important societies in the field of BC (ACR, ESSO, ESTRO, EUSOBI/ESR, and EUSOMA). METHODS: Literature review and expert discussion were performed with the aim of collecting updated information regarding the role of 2-[18F]FDG PET/CT in patients with no special type (NST) BC and summarizing its indications according to scientific evidence. Recommendations were scored according to the National Institute for Health and Care Excellence (NICE) criteria. RESULTS: Quantitative PET features (SUV, MTV, TLG) are valuable prognostic parameters. In baseline staging, 2-[18F]FDG PET/CT plays a role from stage IIB through stage IV. When assessing response to therapy, 2-[18F]FDG PET/CT should be performed on certified scanners, and reported either according to PERCIST, EORTC PET, or EANM immunotherapy response criteria, as appropriate. 2-[18F]FDG PET/CT may be useful to assess early metabolic response, particularly in non-metastatic triple-negative and HER2+ tumours. 2-[18F]FDG PET/CT is useful to detect the site and extent of recurrence when conventional imaging methods are equivocal and when there is clinical and/or laboratorial suspicion of relapse. Recent developments are promising. CONCLUSION: 2-[18F]FDG PET/CT is extremely useful in BC management, as supported by extensive evidence of its utility compared to other imaging modalities in several clinical scenarios.

Locoregional Breast Cancer Recurrence in the European Organisation for Research and Treatment of Cancer 10041/BIG 03-04 MINDACT Trial: Analysis of Risk Factors Including the 70-Gene Signature.

PURPOSE: A number of studies are currently investigating de-escalation of radiation therapy in patients with a low risk of in-breast relapses on the basis of clinicopathologic factors and molecular tests. We evaluated whether 70-gene risk score is associated with risk of locoregional recurrence (LRR) and estimated 8-year cumulative incidences for LRR in patients with early-stage breast cancer treated with breast conservation. METHODS: In this exploratory substudy of European Organisation for Research and Treatment of Cancer 10041/BIG 03-04 MINDACT trial, we evaluated women with a known clinical and genomic 70-gene risk score test result and who had breast-conserving surgery (BCS). The primary end point was LRR at 8 years, estimated by cumulative incidences. Distant metastasis and death were considered competing risks. RESULTS: Among 6,693 enrolled patients, 5,470 (81.7%) underwent BCS, of whom 98% received radiotherapy. At 8-year follow-up, 189 patients experienced a LRR, resulting in an 8-year cumulative incidence of 3.2% (95% CI, 2.7 to 3.7). In patients with a low-risk 70-gene signature, the 8-year LRR incidence was 2.7% (95% CI, 2.1 to 3.3). In univariable analysis, adjusted for chemotherapy, five of 12 variables were associated with LRR, including the 70-gene signature. In multivariable modeling, adjuvant endocrine therapy and to a lesser extent tumor size and grade remained significantly associated with LRR. CONCLUSION: This exploratory analysis of the MINDACT trial estimated an 8-year low LRR rate of 3.2% after BCS. The 70-gene signature was not independently predictive of LRR perhaps because of the low number of events observed and currently cannot be used in clinical decision making regarding LRR. The overall low number of events does provide an opportunity to design trials toward de-escalation of local therapy.

EBCC-14 manifesto: Addressing disparities in access to innovation for patients with metastatic breast cancer across Europe.

The European Breast Cancer Council (EBCC) traditionally identifies controversies or major deficiencies in the management of patients with breast cancer and selects a multidisciplinary expert team to collaborate in setting crucial principles and recommendations to improve breast cancer care. The 2024 EBCC manifesto focuses on disparities in the care of patients with metastatic breast cancer. There are several reasons for existing disparities both between and within countries. Our recommendations aim to address the stigma of metastatic disease, which has led to significant disparities in access to innovative care regardless of the gross national income of a country. These recommendations are for different stakeholders to promote the care of patients with metastatic breast cancer across Europe and worldwide.

Advanced Breast Cancer Guidelines in Latin America: Assessment, Adaptation, and Implementation of Fifth Advanced Breast Cancer Consensus Guidelines.

PURPOSE: As the fifth international consensus on advanced breast cancer (ABC5) established guidelines for the management of this disease, the aim of this article was to present the applicability of the consensus recommendations and to generate knowledge to improve access. METHODS: Sixty-one recommendation statements were selected and discussed by 15 breast cancer experts from Latin America (LA). After the discussion, the level of consensus was determined through a vote. In addition to this, the level of access to each of the recommendations presented, according to the country and health system, was exposed. RESULTS: Latin American experts had a high level of agreement with the ABC5 consensus recommendations (range, 83%-100%). Twelve of 61 statements are not available for all patients in LA. Among the limitations to access, the following ones are described: limited access to certain technologies (stereotactic body radiotherapy, positron emission tomography-computed tomography), the high costs of drugs that limits access to treatment with CDK4/6 inhibitors, pertuzumab, or poly(ADP-ribose) polymerase inhibitors, and the lack of molecular tests for access to therapeutic targets, as well as the difficult geography and cultural diversity of our continent. CONCLUSION: Despite the great relevance of the recommendations of the ABC5 consensus guidelines, we highlight that we still need to improve access for all patients, regardless of the country or health system they are in, for which we call to action to policy makers and patient groups to improve clinical outcomes of patients with advanced breast cancer in our region.

Neoadjuvant pembrolizumab+chemotherapy/adjuvant pembrolizumab for Early-Stage Triple-Negative breast cancer: Quality-of-Life results from randomized KEYNOTE-522 study.

BACKGROUND: In KEYNOTE-522 (NCT03036488), neoadjuvant pembrolizumab+chemotherapy then adjuvant pembrolizumab significantly improved pathological complete response and event-free survival vs neoadjuvant chemotherapy in early-stage triple-negative breast cancer (TNBC). We report patient-reported outcomes (PROs) from KEYNOTE-522. METHODS: Patients were randomized 2:1 to neoadjuvant pembrolizumab 200 mg or placebo every 3 weeks, plus 4 cycles of paclitaxel+carboplatin then 4 cycles of doxorubicin (or epirubicin)+cyclophosphamide. After surgery, patients received adjuvant pembrolizumab or placebo for up to 9 cycles. EORTC QLQ-30 and QLQ-BR23 were prespecified secondary objectives. Between-group differences in least squares (LS) mean change from baseline (day 1/cycle 1 in both neoadjuvant and adjuvant phases) to the prespecified latest time point with ≥60%/80% completion/compliance were assessed using a longitudinal model (no alpha error assigned). RESULTS: Week 21 (neoadjuvant phase) and week 24 (adjuvant phase) were the latest time points at which completion/compliance rates were ≥60%/80%. In the neoadjuvant phase, between-group differences (pembrolizumab+chemotherapy [N = 762] vs placebo+chemotherapy [N = 383]) in LS mean change from baseline to week 21 in QLQ-C30 GHS/QoL, emotional functioning, and physical functioning were -1.04 (95% CI, -3.46 to 1.38), -0.69 (95% CI, -3.13 to 1.75), and -2.85 (95% CI, -5.11 to - 0.60), respectively. In the adjuvant phase, between-group differences (pembrolizumab [N = 539] vs placebo [N = 308]) in LS mean change from baseline to week 24 were -0.41 (95% CI, -2.60 to 1.77), -0.60 (95% CI, -2.99 to 1.79), and -1.57 (95% CI, -3.36 to 0.21). CONCLUSIONS: No substantial differences in PRO assessments were observed between neoadjuvant pembrolizumab+chemotherapy followed by adjuvant pembrolizumab vs neoadjuvant placebo+chemotherapy in early-stage TNBC. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03036488.

EUSOMA quality indicators for non-metastatic breast cancer: An update.

INTRODUCTION: Quality care in breast cancer is higher if patients are treated in a Breast Center with a dedicated and specialized multidisciplinary team. Quality control is an essential activity to ensure quality care, which has to be based on the monitoring of specific quality indicators. Eusoma has proceeded with the up-dating of the 2017 Quality indicators for non-metastatic breast cancer based on the new diagnostic, locoregional and systemic treatment modalities. METHODS: To proceed with the updating, EUSOMA setup a multidisciplinary working group of BC experts and patients' representatives. It is a comprehensive set of QIs for early breast cancer care, which are classified as mandatory, recommended, or observational. For the first time patient reported outcomes (PROMs) have been included. As used in the 2017 EUSOMA QIs, evidence levels were based on the short version of the US Agency for Healthcare Research and Quality. RESULTS: This is a set of quality indicators representative for the different steps of the patient pathway in non-metastatic setting, which allow Breast Centres to monitor their performance with referring standards, i.e minimum standard and target. CONCLUSIONS: Monitoring these Quality Indicators, within the Eusoma datacentre will allow to have a state of the art picture at European Breast Centres level and the development of challenging research projects.

Fertility Preservation and Assisted Reproduction in Patients With Breast Cancer Interrupting Adjuvant Endocrine Therapy to Attempt Pregnancy.

PURPOSE: We investigated time to pregnancy, efficacy and safety of fertility preservation, and assisted reproductive technologies (ARTs) in women with early hormone receptor-positive breast cancer (BC) desiring future pregnancy. PATIENTS AND METHODS: POSITIVE is an international, single-arm, prospective trial, in which 518 women temporarily interrupted adjuvant endocrine therapy to attempt pregnancy. We evaluated menstruation recovery and factors associated with time to pregnancy and investigated if ART use was associated with achieving pregnancy. The cumulative incidence of BC-free interval (BCFI) events was estimated according to the use of ovarian stimulation at diagnosis. The median follow-up was 41 months. RESULTS: Two hundred seventy-three patients (53%) reported amenorrhea at enrollment, of whom 94% resumed menses within 12 months. Among 497 patients evaluable for pregnancy, 368 (74%) reported at least one pregnancy. Young age was the main factor associated with shorter time to pregnancy with cumulative incidences of pregnancy by 1 year of 63.5%, 54.3%, and 37.7% for patients age <35, 35-39, and 40-42 years, respectively. One hundred and seventy-nine patients (36%) had embryo/oocyte cryopreservation at diagnosis, of whom 68 reported embryo transfer after enrollment. Cryopreserved embryo transfer was the only ART associated with higher chance of pregnancy (odds ratio, 2.41 [95% CI, 1.75 to 4.95]). The cumulative incidence of BCFI events at 3 years was similar for women who underwent ovarian stimulation for cryopreservation at diagnosis, 9.7% (95% CI, 6.0 to 15.4), compared with those who did not, 8.7% (95% CI, 6.0 to 12.5). CONCLUSION: In POSITIVE, fertility preservation using ovarian stimulation was not associated with short-term detrimental impact on cancer prognosis. Pregnancy rates were highest among those who underwent embryo/oocyte cryopreservation followed by embryo transfer.

6th and 7th International consensus guidelines for the management of advanced breast cancer (ABC guidelines 6 and 7).

This manuscript describes the Advanced Breast Cancer (ABC) international consensus guidelines updated at the last two ABC international consensus conferences (ABC 6 in 2021, virtual, and ABC 7 in 2023, in Lisbon, Portugal), organized by the ABC Global Alliance. It provides the main recommendations on how to best manage patients with advanced breast cancer (inoperable locally advanced or metastatic), of all breast cancer subtypes, as well as palliative and supportive care. These guidelines are based on available evidence or on expert opinion when a higher level of evidence is lacking. Each guideline is accompanied by the level of evidence (LoE), grade of recommendation (GoR) and percentage of consensus reached at the consensus conferences. Updated diagnostic and treatment algorithms are also provided. The guidelines represent the best management options for patients living with ABC globally, assuming accessibility to all available therapies. Their adaptation (i.e. resource-stratified guidelines) is often needed in settings where access to care is limited.

Capacitação de agentes comunitários de saúde: experiência de ensino e prática com alunos de Enfermagem / Training of community health workers: experience of teaching and practice with nursing students / Formación de trabajadores comunitarios de salud: experiencia de enseñanza y práctica con estudiantes de Enfermería

Trata-se de atividade desenvolvida por estudantes de enfermagem da Escola Superior de Ciências da Saúde, do Distrito Federal, durante o primeiro ano do curso. O objetivo foi realizar uma oficina de capacitação para 22 agentes comunitários de saúde com o intuito de esclarecê-los sobre o seu papel no trabalho comunitário e elevar sua autoestima. Utilizou-se a metodologia da problematização e diversas dinâmicas pedagógicas. Os temas abordados foram: direitos e deveres, atribuições, comunicação, ética, trabalho em equipe, saúde da criança e idoso e violência doméstica. O resultado foi considerado positivo para ambas as partes: os agentes comunitários adquiriram novos conhecimentos/habilidades e sentiram-se mais valorizados, ao passo que os estudantes conseguiram integrar teoria e prática, tornando-se sujeitos ativos do processo ensino-aprendizagem.

This paper aims to report an experience carried out by nursing students from the Undergraduate School of Health Sciences, Federal District, during their first year of study. The objective was to implement a training for 22 community health workers, in order to clarify them about their role in community work and to elevate their self esteem. A methodology of problematization and various educational techniques were used. The themes were: duties and rights, responsibilities, communication, ethics, team work, children´s health, care for the elderly and domestic violence. The result was considered positive for both sides: the community workers acquired new knowledge/capabilities and better feeling of self worth and the students were able to integrate theory and practice and become active participants in the learning process.

Trata-se de actividad desarrollada por alumnos de enfermería de la Escuela Superior de Ciencias de la Salud, del Distrito Federal, durante el primer año de la carrera. El objetivo fue realizar un trabajo de capacitación para 22 agentes comunitarios de salud con el propósito de esclarecerlos sobre su rol en el trabajo comunitario y elevar su autoestima. Fue empleada la metodología de la problematización y diversas dinámicas pedagógicas. Los asuntos abordados fueron: derechos y deberes, atribuciones, comunicación, ética, trabajo en equipo, salud de los niños y de los mayores y violencia doméstica. El resultado fue considerado positivo para las dos partes: los agentes comunitarios obtuvieron nuevos conocimientos/habilidades y se sintieron más valorados, mientras los alumnos lograron integrar teoría y práctica, tornándose sujetos activos del proceso enseñanza/aprendizaje.

Criação e consolidação do curso de enfermagem na Universidade de Brasília: uma história de tutela (1975-1986) / Creation and consolidation of the nursing course at the University of Brasília: a guardianship's history (1975-1986)

O estudo teve como objetivo resgatar a história do curso de Enfermagem da Universidade de Brasília, desde sua criação em 1975, até sua institucionalização definitiva em 1986. As fontes primárias foram depoimentos orais e documentos inscritos. Osresultados revelam que o curso foi criado com mais de 13 anos de atraso, em relação ao proposto no plano diretor, e que, mesmo depois da criação, permaneceu 12 anos sob tutela do Curso de Medicina. Na criação, não houve previsão de infraestrutura,dotação orçamentária ou quadro docente mínimo, o que prejudicou o desenvolvimento do curso. O cursoenfrentou déficit de docentes, evasão discente e falta de autonomia administrativa. Os autores concluem que, mesmo em condições adversas, os docentes de Enfermagem contornaram os jogos de poder e construíram um espaço próprio.

Jogos dramáticos no ensino de enfermagem pediátrica / Dramatic games in the teaching of pediatric nursing

A autora desenvolve a utilização do método psicodramático no ensino da enfermagem pediátrica(AU)

O uso da homeopatia em medicina ortomolecular / The use of homeopathy in orthomolecular medicine

Os homeopatas diariamente prescrevem para pacientes com sintomas carenciais ou toxicos e o fazem sem dados laboratoriais que os comprovem. O avanco tecnologico atual nos oferece condicoes para melhor acompanhamento de nossos casos clinicos durante o tratamento homeopatico. A proposta deste trabalho e demonstrar que nos homeopatas temos condicoes de prescrever nos casos carenciais ou de intoxicacoes com resultados, a principio razoaveis, atraves da analise mineralografica do cabelo. O que nos homeopatas devemos fazer e dar continuidade a pesquisa clinica em medicina ortomolecular, ja que no campo das dinamizacoes homeopaticas, o resultado sempre sera menos agressivo ao organismo(AU)

A eficacia da homeopatia nas intoxicacoes por metais / Eficacy of homeopathy in intoxications by metals

Varias pesquisas tem sido realizadas em homeopatia no campo das intoxicacoes por metais: neste trabalho a autora apresenta o resultado clinico obtido nos pacientes que apresentavam sintomas decorrentes da intoxicacao por algum tipo de metal. Nos pacientes sintomaticos e com analise mineralografica do cabelo que revela a presenca do metal toxico proximo ou acima dos limites de tolerabilidade, a autora demonstra a utilizacao da homeopatia na mobilizacao efetiva deste metal do organismo e a consequente melhora sintomatologica(UA)

O instinto social como sintoma mental / The social instinct as mind symptom

Este trabalho visa facilitar a compreensao dos sintomas mentais mais comuns que deparamos no dia-a-dia da consulta homeopatic, tanto na crianca como no adulto. Atraves da maneira pela qual o individuo se comporta diante das coisas ou pessoas que o circundam, assumindo uma conduta de agressividade ou medo e com uma intensidade maior ou menor (hiper ou hipo) e que nos vai indicar o remedio com todas as suas caracteristicas e modalidades

Avaliaçäo do Programa de Pré-Natal do Posto de Saúde da Vila Municipal, Pelotas - RS / Evaluation of the antenatal care program at Vila Municipal Health Center, Pelotas - RS

Este estudo, através de levantamento epidemiológico, consistiu na avaliaçao do programa de pré-natal que o posto ofereceu à comunidade da Vila Santos Dumont em Pelotas-RS, no período de julho de 1993 a julho de 1994, no sentido de torná-lo mais efetivo. Encontrou-se baixa captaçao de gestantes (35 por cento) e baixa concentraçao de consultas (4,7). Verificou-se que 70 por cento das gestantes tinham entre 20 e 29 anos, apenas oito desconheciam a data da última menstruaçao e a maioria das mulheres residentes na Vila Santos Dumont inscreveram seus filhos no Prograrna de Puericultura. O pré-natal foi considerado adequado quando a gestante ingressava no Programa antes do quinto mês de gestaçao e realizava mais do que cinco consultas no total. Neste estudo encontrou-se 40 por cento das gestantes com pré-natal adequado. Verificou-se que a maioria das gestantes com pré-natal inadequado eram moradoras de outros bairros, suscitando a necessidade de se implantar mecanismos efetivos de regionalizaçao na cidade de Pelotas.

Criaçäo e consolidaçäo do Curso de Enfermagem na Universidade de Brasília: uma história de tutela (1976-1986) / The founding and consolidation of Nursing Program at the University of Brasilia: a history of tutelage (1976-1986)

A presente pesquisa tem como objeto o registro da trajetória histórica do Curso de Enfermagem da Universidade de Brasília (UnB) no período de 1976 a 1986. A história oral e a análise documental apoiaram a reconstruçäo da história da criaçäo e consolidaçäo do Curso no contexto da criaçäo de Brasília, da UnB e da Faculdade de Ciências da Saúde. Em 1975, o entäo Departamento de Assuntos Universitários do Ministério de Educaçäo e Cultura (DAU/MEC), ao verificar que a enfermagem era o curso que menos crescia no país, resolveu priorizar a expansäo do ensino universitário em enfermagem em regiões, entre as quais o Centro-Oeste, onde o contingente formado nesta área era escasso. O Curso de Enfermagem na UnB foi criado neste mesmo ano com mais de dez anos de atraso em relaçäo ao que constava no Plano Orientador da Universidade. Em sua implantaçäo, a UnB declinou-se de receber verbas do MEC, justificando que já dispunha de recursos necessários. A manutençäo da hegemonia médica e política fez com que o Curso de Enfermagem permanecesse sob tutela do departamento do curso de medicina durante 10 anos. Sua liberdade e autonomia foram comprometidas causando prejuízos no processo da construçäo da identidade institucional. Neste período, houve muita luta por área física dedicada ao curso, problemas com a evasäo discente e com a falta de docentes enfermeiros.