Systemic Treatment of Patients With Metastatic Breast Cancer: ASCO Resource-Stratified Guideline

PURPOSE

To guide clinicians and policymakers in three global resource-constrained settings on treating patients with metastatic breast cancer (MBC) when Maximal setting-guideline recommended treatment is unavailable.

METHODS

A multidisciplinary, multinational panel reviewed existing ASCO guidelines and conducted modified ADAPTE and formal consensus processes.

RESULTS

Four published resource-agnostic guidelines were adapted for resource-constrained settings; informing two rounds of formal consensus; recommendations received ≥75% agreement.

RECOMMENDATIONS

Clinicians should recommend treatment according to menopausal status, pathological and biomarker features when quality results are available. In first-line, for hormone receptor (HR)-positive MBC, when a non-steroidal aromatase inhibitor and CDK 4/6 inhibitor combination is unavailable, use hormonal therapy alone. For life-threatening disease, use single-agent chemotherapy or surgery for local control. For premenopausal patients, use ovarian suppression or ablation plus hormone therapy in Basic settings. For human epidermal growth factor receptor 2 (HER2)-positive MBC, if trastuzumab, pertuzumab, and chemotherapy are unavailable, use trastuzumab and chemotherapy; if unavailable, use chemotherapy. For HER2-positive, HR-positive MBC, use standard first-line therapy, or endocrine therapy if contraindications. For triple-negative MBC with unknown PD-L1 status, or if PD-L1-positive and immunotherapy unavailable, use single-agent chemotherapy. For germline BRCA1/2 mutation-positive MBC, if poly(ADP-ribose) polymerase inhibitor is unavailable, use hormonal therapy (HR-positive MBC) and chemotherapy (HR-negative MBC). In second-line, for HR-positive MBC, Enhanced setting recommendations depend on prior treatment; for Limited, use tamoxifen or chemotherapy. For HER2-positive MBC, if trastuzumab deruxtecan is unavailable, use trastuzumab emtansine; if unavailable, capecitabine and lapatinib; if unavailable, trastuzumab and/or chemotherapy (hormonal therapy alone for HR-positive MBC).Additional information is available at www.asco.org/resource-stratified-guidelines. It is ASCO's view that healthcare providers and system decision-makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Improved Survival of Young Patients With Breast Cancer 40 Years and Younger at Diagnosis

PURPOSE

Around 50% of patients with breast cancer in low- or middle-income countries are younger than 50 years, a poor prognostic variable. We report the outcome of patients with breast cancer 40 years and younger.

METHODS

We reviewed 386 patients with breast cancer 40 years and younger and retrieved demographic, clinicopathologic, treatment-related, disease progression, and survival data from electronic medical records.

RESULTS

The median age at diagnosis was 36 years, and infiltrating ductal carcinoma was present in 94.3% of patients, infiltrating lobular carcinoma in 1.3%, and ductal carcinoma in situ in 4.4%. Grade 1 disease was present in 8.5% of patients, grade 2 in 35.5%, and grade 3 in 53.4%; 25.1% had human epidermal growth factor receptor 2 (HER2)-positive, 74.6% had hormone receptor (HR)+, and 16.6% had triple-negative breast cancer. Early breast cancer (EBC) constituted 63.6% (stage I, 22.4%; stage II, 41.2%) of patients, whereas 23.2% had stage III, and 13.2% had metastatic disease at diagnosis. Of patients with EBC, 51% had partial mastectomy and 49.0% had total mastectomy. And 77.1% had chemotherapy with or without anti-HER2 therapy. All HR+ patients received adjuvant hormonal therapy. The disease-free survival at 5 years was 72.5% and 55.9% at 10 years. The overall survival (OS) was 89.4% at 5 years and 76% at 10 years. Patients with stages I/II had an OS of 96.0% at 5 years and 87.1% at 10 years. Patients with stage III had an OS of 88.3% at 5 years and 68.7% at 10 years. The OS of patients with stage IV was 64.5% at 5 years and 48.4% at 10 years.

CONCLUSION

We report survival rates of 89% at 5 years and 76% at 10 years with modern multidisciplinary management. Best results were seen in EBC: OS rates of 96% and 87% at 5 years and 10 years.

Management of breast cancer patients with BRCA gene mutations in Lebanon of the Middle East: perspectives and challenges

BACKGROUND

This commentary explores and discusses the challenges oncologists face in diagnosing and managing breast cancer patients with BRCA gene mutations in Lebanon and the Middle East.

METHODS

Key opinion leaders shared their recommendations to achieve better patient outcomes and satisfaction based on evidence-based medicine and their clinical experience in BRCA management.

RESULTS

Challenges associated with BRCA management can be divided into four main levels: physicians, patients, test, and treatment factors. More genetic counselors are to be identified given their important role in the management of individuals with BRCA gene mutations.

CONCLUSION

Genetic counseling, continuing education, infrastructure, testing, expertise, and financial support are needed to fulfill the unmet needs in the management of BRCA mutation carriers.

Impact of Merit-Based Immigration Policies on Brain Drain From Low- and Middle-Income Countries

PURPOSE

Brain drain is the migration of educated and skilled individuals from a less developed region or country to a more economically established one. The Trump administration proposed a merit-based immigration plan. This article addresses its potential impact on health care delivery in low- and middle-income countries (LMICs) and their preparedness to deal with it.

MATERIALS AND METHODS

Data on immigration policies, numbers of international medical graduates practicing in high-income countries (HICs), various scientific exchange methods, and efforts for capacity building in LMICs.

RESULTS

Talented individuals seek to advance their knowledge and skills, and may stay in HICs because of greater rewards and opportunities. HICs also rely on immigrant international medical graduates to supplement their physician workforces.

CONCLUSION

Ambitious individuals from LMICs need and should have opportunities to advance their education and training in more advanced countries. LMICs should increase their educational efforts, research capabilities, infrastructures, and living conditions to better serve their own populations and reduce their brain drain phenomenon.

Breast cancer treatment: A phased approach to implementation

Optimal treatment outcomes for breast cancer are dependent on a timely diagnosis followed by an organized, multidisciplinary approach to care. However, in many low- and middle-income countries, effective care management pathways can be difficult to follow because of financial constraints, a lack of resources, an insufficiently trained workforce, and/or poor infrastructure. On the basis of prior work by the Breast Health Global Initiative, this article proposes a phased implementation strategy for developing sustainable approaches to enhancing patient care in limited-resource settings by creating roadmaps that are individualized and adapted to the baseline environment. This strategy proposes that, after a situational analysis, implementation phases begin with bolstering palliative care capacity, especially in settings where a late-stage diagnosis is common. This is followed by strengthening the patient pathway, with consideration given to a dynamic balance between centralization of services into centers of excellence to achieve better quality and decentralization of services to increase patient access. The use of resource checklists ensures that comprehensive therapy or palliative care can be delivered safely and effectively. Episodic or continuous monitoring with established process and quality metrics facilitates ongoing assessment, which should drive continual process improvements. A series of case studies provides a snapshot of country experiences with enhancing patient care, including the implementation of national cancer control plans in Kenya, palliative care in Romania, the introduction of a 1-stop clinic for diagnosis in Brazil, the surgical management of breast cancer in India, and the establishment of a women's cancer center in Ghana.

Breast-Gynaecological & Immuno-Oncology International Cancer Conference (BGICC) Consensus and Recommendations for the Management of Triple-Negative Breast Cancer

Background: The management of patients with triple-negative breast cancer (TNBC) is challenging with several controversies and unmet needs. During the 12th Breast-Gynaecological & Immuno-oncology International Cancer Conference (BGICC) Egypt, 2020, a panel of 35 breast cancer experts from 13 countries voted on consensus guidelines for the clinical management of TNBC. The consensus was subsequently updated based on the most recent data evolved lately. Methods: A consensus conference approach adapted from the American Society of Clinical Oncology (ASCO) was utilized. The panellists voted anonymously on each question, and a consensus was achieved when ≥75% of voters selected an answer. The final consensus was later circulated to the panellists for critical revision of important intellectual content. Results and conclusion: These recommendations represent the available clinical evidence and expert opinion when evidence is scarce. The percentage of the consensus votes, levels of evidence and grades of recommendation are presented for each statement. The consensus covered all the aspects of TNBC management starting from defining TNBC to the management of metastatic disease and highlighted the rapidly evolving landscape in this field. Consensus was reached in 70% of the statements (35/50). In addition, areas of warranted research were identified to guide future prospective clinical trials.

Enhancing global access to cancer medicines

Globally, cancer is the second leading cause of death, with numbers greatly exceeding those for human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria combined. Limited access to timely diagnosis, to affordable, effective treatment, and to high-quality care are just some of the factors that lead to disparities in cancer survival between countries and within countries. In this article, the authors consider various factors that prevent access to cancer medicines (particularly access to essential cancer medicines). Even if an essential cancer medicine is included on a national medicines list, cost might preclude its use, it might be prescribed or used inappropriately, weak infrastructure might prevent it being accessed by those who could benefit, or quality might not be guaranteed. Potential strategies to address the access problems are discussed, including universal health coverage for essential cancer medicines, fairer methods for pricing cancer medicines, reducing development costs, optimizing regulation, and improving reliability in the global supply chain. Optimizing schedules for cancer therapy could reduce not only costs, but also adverse events, and improve access. More and better biomarkers are required to target patients who are most likely to benefit from cancer medicines. The optimum use of cancer medicines depends on the effective delivery of several services allied to oncology (including laboratory, imaging, surgery, and radiotherapy). Investment is necessary in all aspects of cancer care, from these supportive services to technologies, and the training of health care workers and other staff.

Cancer Care for Refugees and Displaced Populations: Middle East Conflicts and Global Natural Disasters

Conflicts and natural disasters can cause major disruptions to people's lives. Media and news agencies usually focus on immediate consequences of these events, including loss of life and injuries, environmental and property destruction, and relief efforts. In this article, we will examine the effects of conflicts (focusing on in the Middle East) and global natural disasters on patients already diagnosed with cancer and on those who are diagnosed with cancer during and in the immediate aftermath of these events. We will review the limited literature, provide situational analysis, and discuss medical relief efforts, governmental readiness, and the role of United Nations agencies and international nongovernmental organizations. We will also discuss treatment of patients with cancer in the context of prolonged displacements and limited resources.

American Society of Clinical Oncology's Global Oncology Leadership Task Force: Findings and Actions

In response to rising cancer incidence and mortality rates in low- and middle-income countries and the increasingly global profile of ASCO’s membership, the ASCO Board of Directors appointed the Global Oncology Leadership Task Force (Task Force) to provide recommendations on ASCO’s engagement in global oncology. To accomplish its work, the Task Force convened meetings of global oncology experts, conducted focus group discussions with member groups, did site visits to South America and India, and met regularly to analyze the findings and develop recommendations. Task Force findings included global concerns, such as access to care, and specific concerns of middle- and low-resource settings. The need to strengthen health systems and the importance of alliances with a range of international cancer stakeholders were emphasized. Task Force recommendations to the ASCO Board of Directors were based on a three-part global oncology strategy of professional development, improvement of access to quality care, and acceleration of global oncology research. Specific areas of focus within each of these strategic pillars are provided along with an update on areas of ASCO activity as these recommendations are implemented.

Practice and Impact of Multidisciplinary Tumor Boards on Patient Management: A Prospective Study

PURPOSE

Multidisciplinary tumor boards (MTBs) have become commonplace. The use, attendance, and function of MTBs need continued assessment and improvement.

METHODS

We prospectively recorded and assessed all cases presented at MTBs between October 2013 and December 2014. Data were collected before and during each MTB. Data were analyzed using SPSS for Windows version 23 (SPSS, Chicago, IL).

RESULTS

Five hundred three cases were presented: 234 cases (46%) at GI cancer MTBs, 149 cases (29.6%) at breast cancer MTBs, 69 cases (13.7%) at thoracic/head and neck cancer MTBs, and 51 cases (10.7%) at neuro-oncology MTBs. A total of 86.7% of MTB cases were presented to make plans for management. Plans for upfront management were made in 67% of the breast cancer cases, 63% of GI cases, 59% of thoracic/head and neck cases, and 49% of neuro-oncology cases. Three hundred ninety-four cases (78.3%) were presented by medical oncologists, whereas only 74 cases (14.7%) were presented by surgeons, and 10 cases (2%) were presented by radiation oncologists. The majority of MTBs, with the exception of the neurosurgery MTBs, were led by medical oncologists. Surgeons presented the least number of cases but attended the most, and their contributions to discussions and decision making were essential.

CONCLUSION

MTBs enhance the multidisciplinary management of patients with cancer. Upfront multidisciplinary decision making should be considered as an indicator of benefit from MTBs, in addition to changes in management plans made at MTBs. Increasing the contributions of surgeons to MTBs should include bringing more of their own cases for discussion.

Management of locally advanced and metastatic breast cancer: guidelines, infrastructures and low resource settings

Breast cancer incidence is rising and it accounts for over 1.6 million cases per year worldwide. It represents about one-third of female cancers and is a significant health issue in countries at all economic levels. In this article, we review global cancer statistics, breast cancer staging including late-stage presentation in limited resource settings, disparities in the breast cancer outcomes and requirements for optimal management, including infrastructure needs for optimal surgery, radiation treatment and systemic therapy. We will discuss controversies related to drug pricing and availability, process and delays in registration of new drugs as well as resource stratification and resource-stratified guidelines for locally advanced breast cancer and metastatic breast cancer.

Overview, prevention and management of chemotherapy extravasation

Chemotherapy extravasation remains an accidental complication of chemotherapy administration and may result in serious damage to patients. We review in this article the clinical aspects of chemotherapy extravasation and latest advances in definitions, classification, prevention, management and guidelines. We review the grading of extravasation and tissue damage according to various chemotherapeutic drugs and present an update on treatment and new antidotes including dexrazoxane for anthracyclines extravasation. We highlight the importance of education and training of the oncology team for prevention and prompt pharmacological and non-pharmacological management and stress the availability of new antidotes like dexrazoxane wherever anthracyclines are being infused.

Tumor boards: optimizing the structure and improving efficiency of multidisciplinary management of patients with cancer worldwide

Multidisciplinary management tumor boards are now conducted worldwide for the management of patients with cancer. Studies evaluating their influence on decision making and patient outcome are limited; however, single-center studies have reported significant changes in diagnosis and treatment plans. A survey from Arabic countries showed widespread use and reliance on tumor boards for decision making. A recent multi-institutional survey of veteran affairs (VA) hospitals in the United States found limited association between the presence of tumor boards and care and outcomes. The Cancer Care Outcomes Research and Surveillance Consortium looked at the association between tumor board features and measures of quality of care. Results of overall survival among the patients of these physicians participating in tumor boards is ongoing, but preliminary results are outlined along with a recent ASCO survey of international members on the presence, utilization, and influence of tumor boards in this article. Tumor boards allow for implementation of clinical practice guidelines and may help capture cases for clinical trials. Efforts to improve preparations, structure, and conduct of tumor boards, research methods to monitor their performance, teamwork, and outcomes are outlined also in this article. The concept of mini-tumor boards and more efficient methods for MDM in countries with limited resources are also discussed. In suboptimal settings, such as small community hospitals, rural areas, and areas with limited resources, boundaries in diagnosis and management can be overcome, or at least improved, with tumor boards, especially with the use of video-conferencing facilities. Studies from the United Kingdom showed that special training of multidisciplinary teams (MDT) led to better team dynamics and communication, improved patient satisfaction, and improved clinical outcome. The weight of the benefits versus the time and effort spent to improve efficiency, patient care, and better time management in the United States and in the international oncology community is also reviewed in this article.

Global Practice and Efficiency of Multidisciplinary Tumor Boards: Results of an American Society of Clinical Oncology International Survey

PURPOSE

Multidisciplinary tumor boards (MDTBs) are universally recommended, but recent literature has challenged their efficiency.

METHODS

The American Society of Clinical Oncology (ASCO) conducted a survey of a randomly selected cohort of international ASCO members. The survey was built on SurveyMonkey and was sent via e-mail to a sample of 5,357 members.

RESULTS

In all, 501 ASCO members practicing outside the United States responded, and 86% of them participated in MDTBs at their own institutions. Those who attended represented a variety of disciplines in 70% to 86% of all MDTBs. The majority of MDTBs held weekly specialty and/or general meetings. Eighty-nine percent of 409 respondents attended for advice on treatment decisions. Survey respondents reported changes of 1% to 25% in treatment plans for 44% to 49% of patients with breast cancer and in 47% to 50% of patients with colorectal cancer. They reported 25% to 50% changes in surgery type and/or treatment plans for 14% to 21% of patients with breast cancer and 12% to 18% of patients with colorectal cancer. Of the 430 respondents 96% said overall benefit to patients was worth the time and effort spent at MDTBs, and 96% said that MDTBs have teaching value. Mini tumor boards held with whatever types of specialists were available were considered valid. In all, 94.8% (425 of 448) said that MDTBs should be required in institutions in which patients with cancer are treated.

CONCLUSION

MDTBs are commonplace worldwide. A majority of respondents attend them to obtain recommendations, and they report changes in patient management. Change occurred more frequently with nonmedical oncologists and with physicians who had less than 15 years in practice. MDTBs helped practitioners make management decisions. Mini tumor boards may improve time efficiency and are favored when the full team is not available. Suggestions for improving MDTBs included making them more efficient, better selection and preparation of cases, choosing an effective team leader, and improving how time is used, but more research is needed on ways to improve the efficiency of MDTBs.

Enhancing cancer care in areas of limited resources: our next steps

In-depth knowledge of local conditions is necessary in order to enhance care in low- and middle-income countries. In this review we discuss: improving cancer diagnosis, optimizing patient management, increasing health awareness, prevention, early detection, eradication of causative infectious diseases and agents, tobacco control, healthy diets and lifestyles, availability of diagnostic methods, easy access to care, affordable costs, improving infrastructures, quality care measures, implementing and adapting guidelines, multidisciplinary management, supportive and survivorship care, research and optimization of medical school curriculum and training in oncology. Establishment of national cancer control plans by policy makers, physician societies, medical schools, and patient advocates is recommended. We will review evidence and controversies, and outline the next steps needed to prevent cancer and enhance care of cancer patients in LMICs.

BRCA1 and BRCA2 mutations in ethnic Lebanese Arab women with high hereditary risk breast cancer

PURPOSE

Breast cancer is the most common malignancy among women in Lebanon and in Arab countries, with 50% of cases presenting before the age of 50 years.

METHODS

Between 2009 and 2012, 250 Lebanese women with breast cancer who were considered to be at high risk of carrying BRCA1 or BRCA2 mutations because of presentation at young age and/or positive family history (FH) of breast or ovarian cancer were recruited. Clinical data were analyzed statistically. Coding exons and intron-exon boundaries of BRCA1 and BRCA2 were sequenced from peripheral blood DNA. All patients were tested for BRCA1 rearrangements using multiplex ligation-dependent probe amplification (MLPA). BRCA2 MLPA was done in selected cases.

RESULTS

Overall, 14 of 250 patients (5.6%) carried a deleterious BRCA mutation (7 BRCA1, 7 BRCA2) and 31 (12.4%) carried a variant of uncertain significance. Eight of 74 patients (10.8%) aged ≤40 years with positive FH and only 1 of 74 patients (1.4%) aged ≤40 years without FH had a mutated BRCA. Four of 75 patients (5.3%) aged 41-50 years with FH had a deleterious mutation. Only 1 of 27 patients aged >50 years at diagnosis had a BRCA mutation. All seven patients with BRCA1 mutations had grade 3 infiltrating ductal carcinoma and triple-negative breast cancer. Nine BRCA1 and 17 BRCA2 common haplotypes were observed.

CONCLUSION

Prevalence of deleterious BRCA mutations is lower than expected and does not support the hypothesis that BRCA mutations alone cause the observed high percentage of breast cancer in young women of Lebanese and Arab descent. Studies to search for other genetic mutations are recommended.

Breast cancer in low and middle income countries (LMICs): a shifting tide in global health

Cancer control planning has become a core aspect of global health, as rising rates of noncommunicable diseases in low-resource settings have fittingly propelled it into the spotlight. Comprehensive strategies for cancer control are needed to effectively manage the disease burden. As the most common cancer among women and the most likely reason a woman will die from cancer globally, breast cancer management is a necessary aspect of any comprehensive cancer control plan. Major improvements in breast cancer outcomes in high-income countries have not yet been mirrored in low-resource settings, making it a targeted priority for global health planning. Resource-stratified guidelines provide a framework and vehicle for designing programs to promote early detection, diagnosis, and treatment using existing infrastructure and renewable resources. Strategies for evaluating the current state and projecting future burden is a central aspect of developing national strategies for improving breast cancer outcomes at the national and international levels.

International screening and early detection of breast cancer: resource-sensitive, age- and risk-specific guidelines

SUMMARY 

In this article we review the evidence and current controversies surrounding screening and early detection of breast cancer, from the initially positive age-specific randomized trials of the 1970s and 1980s, to the 2009 USPSTF recommendations, 2013 interpretation of SEER data, 2014 Canadian Study updates, and BHGI resource-sensitive guidelines, as well as the few reports available from emerging countries. We will also discuss the burden of breast cancer in low- and middle- income countries with rising incidence rates and advanced stages at presentation, the need for increasing awareness and downstaging of disease. We will discuss the data putting it in perspective for general guidelines for the international scene, and suggest adoption of evidence-based resource-sensitive and risk-specific guidelines, with less reliance on broad age-specific guidelines.

Outcome of Breast Cancer Patients Treated outside of Clinical Trials

Background: Information on outcome of breast cancer patients treated in the community is scarce. Data on outcome of patients treated in real-life clinical practice may provide useful information for performance improvement.

Methods: Study population is from a single institution practice at the American University of Beirut Medical Center. Demographics, clinical characteristics and survival data on patients diagnosed 1997-2010 in two IRB-approved studies were entered and analyzed on SPSS program. Survival was estimated using Kaplan Meier Method.

Findings: Total was 519 patients. 23.9% had stage I, 39.7% stage II, 30.4% Stage III and 6% stage IV. ER positive in 74.4% of patients. 30.6% of patients <35 had TNBC compared to 12.3% for the whole group. 45.9% of non-metastatic patients had breast-conserving therapy (BCT). BCT rates increased to 64% during the second half of the study, coinciding with increasing awareness and changing cultural mores. 5-year and 10-year overall survivals for stage I were 98.9% and 80.5%, 89.2% and 70.7% for stage II, 67.6% and 35.5% for stage III, and 39.1% and 26.1% for stage IV respectively.

Interpretation: Patients treated outside clinical trials in a multidisciplinary fashion according to guidelines have comparable, and at times better, survival compared to data from trials or population statistics. Locally generated outcome data could be valuable for evaluating results of treatment at individual practices for the purpose of quality assessment and improvement. Our data also provides report of increased rate of breast conserving surgery from Middle East.

Management of Paclitaxel-induced hand-foot syndrome

BACKGROUND

Hand-foot syndrome (HFS), also known as acral erythema or palmoplantar dysesthesia, is a manifestation of painful erythema and dysesthesia mostly occurring in the palms and soles. Although many chemotherapeutic agents have been shown to cause HFS, it remains an uncommon adverse cutaneous manifestation of paclitaxel.

CASE REPORT

We report a case of paclitaxel-induced grade 3 HFS in a patient with breast cancer. HFS developed after 6 weeks of paclitaxel weekly infusions. The patient was managed by avoidance of sun exposure and extensive use of sunscreen and moisturizers. The skin lesions stabilized and improved gradually. This allowed us to continue the planned necessary course of 12 weeks of paclitaxel under close surveillance.

CONCLUSION

Paclitaxel-induced HFS can be managed with topical creams and avoidance of sun exposure without the need to discontinue chemotherapy. However, close monitoring for any increase or change in symptoms is warranted.

Epidemiology and prognosis of breast cancer in young women

Breast cancer is the most common malignancy in women with 6.6% of cases diagnosed in young women below the age of 40. Despite variances in risk factors, Age Standardized Incidence Rates of breast cancer in young women vary little between different countries. Review of modifiable risk factors shows that long-term use of oral contraceptives, low body mass index (BMI) and high animal fat diet consumption are associated with increased risk of premenopausal breast cancer. Decreased physical activity and obesity increase risks of breast cancer in postmenopausal women, but data on premenopausal women rather shows that high BMI is associated with decreased risk of breast cancer. Non-modifiable risk factors such as family history and genetic mutations do account for increased risks of breast cancer in premenopausal women. Breast cancer in young women is associated with adverse pathological factors, including high grade tumors, hormone receptor negativity, and HER2 overexpression. This has a significant negative impact on the rate of local recurrence and overall survival. Moreover, younger women often tend to present with breast cancer at a later stage than their older counterparts, which further explains worse outcome. Despite these factors, age per se is still being advocated as an independent role player in the prognosis. This entails more aggressive treatment modalities and the need for closer monitoring and follow-up.

ASCO's International programs and how you can become involved

The American Society of Clinical Oncology (ASCO) is dedicated to serving its members and to reducing disparities in the treatment of patients with cancer and their outcome. ASCO has a portfolio of international programs called ASCO International that aims to improve clinical practice by sharing oncology knowledge through a network of ASCO members and partners. In order to achieve its goals, ASCO has an International Affairs Committee that oversees many programs that involve a global exchange of knowledge through courses and workshops, mentoring, initiatives promoting research, and specialty training standards. All of these programs depend on ASCO member volunteers in one capacity or another.

Clinicopathologic and immunohistochemical characteristics of male breast cancer: a single center experience

Male breast cancer (MaleBC) is a rare tumor that has been insufficiently described in the Middle East. The purpose of this study is to report the first MaleBC series in Lebanon, describing its clinicopathologic and immunohistochemical phenotype, and how it compares with MaleBC in the West and with female breast cancer in Lebanon and the Middle East. Forty-seven cases of MaleBC were reviewed. Results showed younger ages at presentation (62 years versus 67 years), higher incidence of lobular carcinoma (6% versus 1%), and more frequent p53 positivity and axillary node metastases in our series than in those reported about MaleBC. Other results such as higher estrogen receptor (ER) positivity and lower HER-2/neu over-expression were comparable to the literature. These findings suggest that MaleBC in our region may represent a biologically different tumor with potentially distinct prognostic and therapeutic implications.

Breast cancer management in low resource countries (LRCs): consensus statement from the Breast Health Global Initiative

The Breast Health Global Initiative (BHGI) brought together international breast cancer experts to discuss breast cancer in low resource countries (LRCs) and identify common concerns reviewed in this consensus statement. There continues to be a lack of public and health care professionals' awareness of the importance of early detection of breast cancer. Mastectomy continues to be the most common treatment for breast cancer; and a lack of surgeons and anesthesia services was identified as a contributing factor in delayed surgical therapy in LRCs. Where available, radiation therapy is still more likely to be used for palliation rather than for curative treatment. Tumor receptor status is often suboptimally performed due to lack of advanced pathology services and variable quality control of tissue handling and processing. Regional pathology services can be a cost-effective approach and can serve as reference, training and research centers. Limited availability of medical oncologists in LRCs often results in non-specialist providing chemotherapeutic services, which requires additional supervision and training. Palliative care is an emerging field in LRCs that requires investment in training and infrastructure development. A commitment and investment in the development of breast cancer care services by LRC governments and health authorities remains a critical need in LRCs.

Complete response of brain metastases from breast cancer overexpressing Her-2/neu to radiation and concurrent Lapatinib and Capecitabine

Breast cancers that overexpress the human epidermal growth factor receptor 2 (HER-2) have a predilection to metastasize to the brain. Therapeutic options for brain metastases with systemic therapy remain a challenge in those patients since targeted and chemotherapeutic agents have limited penetration through the blood-brain barrier. Here we report the case of a patient with brain metastases from breast cancer overexpressing HER-2 who achieved a complete radiologic response after treatment by radiation and concurrent Lapatinib and Capecitabine.

Breast cancer issues in developing countries: an overview of the Breast Health Global Initiative

BACKGROUND

Of the 411,000 breast cancer deaths around the world in 2002, 221,000 (54%) occurred in low- and middle-income countries (LMCs). Guidelines for breast health care (early detection, diagnosis, and treatment) that were developed in high-resource countries cannot be directly applied in LMCs, because these guidelines do not consider real world resource constraints, nor do they prioritize which resources are most critically needed in specific countries for care to be most effectively provided.

METHODS

Established in 2002, the Breast Health Global Initiative (BHGI) created an international health alliance to develop evidence-based guidelines for LMCs to improve breast health outcomes. The BHGI held two Global Summits in October 2002 (Seattle) and January 2005 (Bethesda) and using an expert consensus, evidence-based approach developed resource-sensitive guidelines that define comprehensive pathways for step-by-step quality improvement in health care delivery.

RESULTS

The BHGI guidelines, now published in English and Spanish, stratify resources into four levels (basic, limited, enhanced, and maximal), making the guidelines simultaneously applicable to countries of differing economic capacities. The BHGI guidelines provide a hub for linkage among clinicians and alliance among governmental agencies and advocacy groups to translate guidelines into policy and practice.

CONCLUSIONS

The breast cancer problem in LMCs can be improved through practical interventions that are realistic and cost-effective. Early breast cancer detection and comprehensive cancer treatment play synergistic roles in facilitating improved breast cancer outcomes. The most fundamental interventions in early detection, diagnosis, surgery, radiation therapy, and drug therapy can be integrated and organized within existing health care schemes in LMCs. Future research will study what implementation strategies can most effectively guide health care system reorganization to assist countries that are motivated to improve breast cancer outcome in their populations.

Guidelines for breast cancer screening in Lebanon Public Health Communication

The accumulation of national epidemiological data since the late 1990s has led to the adoption of evidence-based guidelines for breast cancer screening in Lebanon (2006). Almost 50% of breast cancer patients in Lebanon are below the age of 50 years and the age-adjusted incidence rate is estimated at 69 new cases per 100,000 per year (2004). This official notification calls for breast self-examination (BSE) every month starting age 20, and a clinical breast examination (CBE) performed by a physician every three years between the ages of 20 and 40 years. Starting age 40, and for as long as a woman is in good health, an annual CBE and mammography are recommended. Women with known genetic family history of breast cancer should start screening 10 years earlier than the first young patient in the family, or earlier depending on medical advice. The Breast Cancer National Task Force (BCNTF) recommends certification of mammography centers and continued training of personnel to assure high quality mammograms, and to minimize unnecessary investigations and surgeries.It recommends that a national program should record call-backs of women for annual screening and follow-up data on abnormal mammograms. BCNTF encourages the adoption of these guidelines and monitoring of their results, as well as follow-up of breast cancer epidemiology and registry in Lebanon, and scientific progress in early breast cancer detection to determine needs for modifications in the future.

Responding to the challenges of breast cancer in egypt and other arab countries

Physicians in Egypt and other Arab and developing countries still have to deal on a daily basis with large numbers of patients with advanced stages of breast cancer at presentation. Efforts at measuring the magnitude of the breast cancer issues, epidemiology, and awareness, are now moving further in the right direction. We are now starting to face the challenges of early detection of breast cancer as well as the implementation of proper modern management. Dorria S. Salem et al. publish in this issue of the Journal of Egyptian NCI an outline and initial results of a very ambitious Women Health Outreach Program (WHOP) designed to be completed in 5 phases 1. She and her co-authors state that those 5 phases include a prior training and demonstration phase that was completed in the Imaging Unit of Kasr El Aini Hospital in Cairo, as well as a one-year pilot phase completed between October 2007 and October 2008. Authors present us with results of screening of 20.098 women over the age of 45 years, between October 30, 2007 and February 9, 2009 in Cairo, Alexandria and Suez Governorates in Egypt. In addition to breast cancer, WHOP included screening for diabetes, hypertension and obesity. WHOP investigators are to be congratulated for this extraordinary ambitious project and all the efforts put into it. They were well prepared in regards to having a multi-disciplinary working team and they included in their project programs for training of clerks, data managers, radiographers, nurses, radiologists and other physicians who deal with diagnosis and management of breast cancer. They also included engineers and arranged for mobile units to reach women who could not otherwise reach them. WHOP investigators are to be commended also for performing a field plan demonstration project and testing it and for measuring citizens' response before finalizing their plans and starting the project1. They set a great example for other people working in the field. Breast cancer is the most common female malignancy in women in almost all Arab countries [2-5]. Randomized trials of mammographic screening of average-risk women above 50 years reduced breast cancer mortality by more than 36%. Analysis of the eight randomized trials, including the Canadian trials on women, ages 40-49 years old, showed a relative reduction of breast cancer deaths by 18% [6]. There is an obvious overlap as women with ages ranging from 40-49 years old reach the age of 50 and above, and enjoy the more clear benefits of mammographic screening beyond the age of 50 years. Many societies, including the American Cancer Society, recommend mammographic screening starting at age 40 years [7,8]. As it would be very difficult in this day and age to do more studies on breast cancer screening, and in view of the observations that almost 50% of cases are below the age of 50 years with a median age of 48-52 years at presentation, we recommend screening be done starting age 40, where resources are available and where setup for breast cancer care is appropriate [4,9]. Salem et al. report an initial very significant and alarming number of 10.215 women out of 20.098 women to be overweight and 2692 women to be obese [1]. Their observation that there is no significant correlation with breast cancer is only a one point in time observation and it cannot be used to confirm or refute any potential relationship between overweight, obesity and breast cancer. Future results, follow-up, and multivariate analysis will be awaited. Correlation of mammographic abnormalities with diabetes and hypertension in WHOP participants are very preliminary and will also need further multivariate analysis. WHOP investigators report that they invited women aged 45 years and up for screening. Eligibility criteria listed include only two points, women should have no personal history of breast cancer and no recent mammography [1], authors neither describe clinical history nor physical breast examination of selected and invited women. In future reports, authors will be asked about the assessement of those invited women, and what were the results and outcome if referred women were found to have abnormalities in their breasts. In another study from Cairo, Egypt, women were taught how to examine themselves, and authors reported that many were found to have clinical breast cancers for which they were effectively downstaged, and therefore treated for cancers that would have otherwise presented later as more advanced cases [10]. This issue brings me back to re-emphasize the importance of awareness, teaching women self-breast exam, and clinical breast examination once-a-year by a physician, particularly in countries with limited resources. Breast cancer awareness campaigns emphasize the benefits of early detection by promoting breaking of taboos, and teaching scientific facts that early breast cancer can be cured, and that cure can be achieved without the need of mastectomy. Advanced breast cancer is devastating to women and to their husbands and children, and therefore campaigns should be directed towards women as well as husbands who should be asked to encourage their wives to enroll in screening campaigns. Campaigns have begun to reduce the effects of taboos and people started to talk more freely about cancer, in fact, we and many centers in Arab countries have started to see more cases of early breast cancer and even a significant number of cases with microcalcifications [4]. Breast cancer screening in countries with limited resources have been recently reviewed [11,12]. As for the management of abnormal findings, Dorria S. Salem et al. [1] report performing FNAB as first line management in suspicious cases and reserving core biopsies for inconclusive cases. I fully agree with the authors' efforts to ensure accurate diagnosis and the importance of having an experienced cytopathologist. However, FNA is useful and recommended when there is a palpable tumor or a highly suspicious tumor with irregular borders and infiltrative characteristics on mammography and ultrasound. Core biopsy is indicated when FNA is inconclusive as the authors state, and also if mammography shows micro-calcifications where FNA cannot distinguish between in-situ and infiltrative carcinoma. A core biopsy is important for better assessment of pathology and determination of receptors (estrogen, progesterone, and HER2 receptors) especially in patients with large tumors who require preoperative (neoadjuvant) therapy, particularly when targeted anti-HER2 therapy is indicated [13]. In the present report, WHOP investigators [1] report that 31 patients, out of 86 true positive cancers, underwent modified radical mastectomy while 21 had breast-conserving surgery. Eleven patients required only excisional biopsy and had benign tumors, 25 had surgery at private institutions and no data is available on them. Further WHOP reports will be awaited to report to us on the stages and follow-up information on all patients. Availability of experienced surgeons and radiation oncology are also important issues when referring patients for partial or total mastectomy. After screening of over 20000 women, authors report that abnormal mammographies with BiRADS 4 and 5 were found in 433 cases (reported as 2.1%). Additional work-up with ultrasound and FNA/biopsy showed 2 false negatives, 110 false positives, and confirmed 86 true positive cases (0.4% of total 20.098 women screened). In the US, the likelihood of a woman being called back for additional testing after first round of screening is an average of 11% (range 3-57%) [14]. In women for whom a biopsy is then indicated, the likelihood of finding an invasive and/or insitu cancer is 25-47% [15]. This is what we call positive predictive value (PPV) and it varies with expertise and patients own risk factors for breast cancer. What is of concern in this present WHOP article, although not unexpected, is that more than half of the recalled women did not show up or no feedback is available on them. This should generate yet another important experience on how to deal with missing information and how to assure follow-up of patients in Egypt and other Arab countries, as well as in all limited resource countries. WHOP investigators will be asked to report in the future on screening intervals and data collection. Screening started at age 45 years, and data were analyzed by 10-year age groups starting age 50, which makes comparisons somehow difficult. In view of the high incidence of women with breast cancer with young age at presentation, it would be more helpful if WHOP investigators revise the starting age for screening mammography and make it 40 years and analyze data according to 10-year age groups starting age 40 years. On the other hand, it is important to note that increasing the time interval of periodic mammography diminished the mortality reduction by allowing undetected growth of interval cancers. Increasing the screening interval of women in their forties from annual to every 2 years or to every 3 years would diminish mortality reduction rates from 36% to 18% and to 4%, respectively [16]. Once a screening strategy is adopted, women aged 40 years and up should be screened at yearly intervals because data from Egypt and other Arab countries indicate that 50% of breast cancers are seen in women below age 50 years, and because young women have more aggressive tumors [17,18] and may be missed by two-year intervals. Finally, WHOP investigators, staff, and their sponsors are to be commended for this excellent, well planned and executed project that sets a great example for devotion for science and public health. In addition to regional and national cancer registries, they provide many new innovative approaches to characterize, diagnose and treat breast cancer in Egypt and other Arab countries. (ABSTRACT TRUNCATED)

Effects of young age at presentation on survival in breast cancer

Background

Young age remains a controversial issue as a prognostic factor in breast cancer. Debate includes patients from different parts of the world. Almost 50% of patients with breast cancer seen at the American University of Beirut Medical Center (AUBMC) are below age 50.

Methods

We reviewed 1320 patients seen at AUBMC between 1990 and 2001. We divided them in three age groups: Below 35, 35–50, and above 50. Data and survival were analyzed using Chi-square, Cox regression analysis, and Kaplan Meier.

Results

Mean age at presentation was 50.8 years. 107 patients were below age 35, 526 between 35–50 and 687 patients above age 50. Disease stages were as follows: stage I: 14.4%, stage II: 59.9%, stage III: 20% and stage IV: 5.7%. Hormone receptors were positive in 71.8% of patients below 35, in 67.6% of patients 35–50 and in 78.3% of patients above 50. Grade of tumor was higher as age at presentation was lower. More young patients received anthracycline-based adjuvant chemotherapy. Of hormone receptor-positive patients, 83.8% of those below age 35 years, 87.76% of those aged 35–50 years, and 91.2% of those aged above 50 years received adjuvant tamoxifen. The mean follow up time was 3.7 +/- 2.9 years. Time to death was the only variable analyzed for survival analysis. Excluding stage IV patients, tumor size, lymph node, tumor grade and negative hormone receptors were inversely proportional to survival. Higher percentage of young patients at presentation developed metastasis (32.4% of patients below 35, as compared to 22.9% of patients 35–50 and 22.8% of patients above 50) and had a worse survival. Young age had a negative impact on survival of patients with positive axillary lymph nodes, and survival of patients with positive hormonal receptors, but not on survival of patients with negative lymph nodes, or patients with negative hormonal receptors.

Conclusion

Young age at presentation conferred a worse prognosis in spite of a higher than expected positive hormone receptor status, more anthracycline-based adjuvant chemotherapy and equivalent adjuvant tamoxifen hormonal therapy in younger patients. This negative impact on survival was seen in patients with positive lymph nodes and those with positive hormonal receptors.

Angiogenesis and cancer: A cross-talk between basic science and clinical trials (the "do ut des" paradigm)

Angiogenesis plays a crucial role in facilitating tumor growth and the metastatic process, and it is the result of a dynamic balance between pro-angiogenic factors, like vascular endothelial growth factor (VEGF) and platelet-derived growth factor, and antiangiogenic factors, like thrombospondin-1 and angiostatin. Many drugs that target human tumors, like bevacizumab and some VEGF-receptor tyrosine-kinase inhibitors (e.g., BAY 43-9006, SU11248 and PTK787/ZK222584) have been studied in clinical trials, with favorable toxicity reports and encouraging results in advanced colorectal cancer, renal cell cancer, breast cancer and non-squamous non-small cell lung cancer, either combined with chemotherapy, or in monotherapy. Another potential approach to inhibiting angiogenesis is through metronomic chemotherapy (low doses of chemotherapy for long periods of time). This review describes the mechanisms of the angiogenic process and evaluates the recent data about antiangiogenic therapies in clinical trials.

Unilateral anterior uveitis complicating zoledronic acid therapy in breast cancer

Background

Zoledronic acid is very widely used in patients with metastatic bone disease and osteoporosis. Only one case of bilateral uveitis was recently reported related to its use.

Case presentation

We report the first case of severe unilateral anterior uveitis in a patient with breast cancer and an intraocular lens. Following zoledronic acid infusion, the patient developed severe and dramatic right eye pain with decreased visual acuity within 24 hours and was found to have a fibrinous anterior uveitis of moderate severity The patient was treated with topical prednisone and atropine eyedrops and recovered slowly over several months.

Conclusion

Internists, oncologists, endocrinologists, and ophtalmologists should be aware of uveitis as a possible complication of zoledronic acid therapy. Patients should be instructed to report immediately to their physicians and treatment with topical prednisone and atropine eyedrops should be instituted immediately at the onset of symptoms. This report documents anterior uveitis as a complication of zoledronic acid therapy. This reaction could be an idiosyncratic one but further research may shed more light on the etiology.

Erysipelas of the upper extremity following locoregional therapy for breast cancer

Cellulitis is a well-known complication of lymphedema of the lower extremities. Erysipelas of the upper extremity complicating breast cancer therapy has never been reported in the English-language literature. We describe seven breast cancer patients with erysipelas of the upper extremity. Five had a predisposing injury to the extremity. All patients responded very well to intravenous antibiotics without any sequelae. They had rapid resolution with typical desquamation. No long-term sequelae were seen except for mild increase of lymphedema. Erysipelas should be listed as a rare complication after locoregional therapy for breast cancer. Intravenous penicillin should be used as the initial therapy. Prevention of arm lymphedema and avoidance of any trauma to the arm are important prophylactic measures. Sentinel lymph node biopsy reduces the rate of axillary lymph node dissection and thus should reduce the incidence of lymphedema and erysipelas.

Trauma-associated growth of suspected dormant micrometastasis

BACKGROUND

Cancer patients may harbor micrometastases that remain dormant, clinically undetectable during a variable period of time. A traumatic event or surgery may trigger the balance towards tumor growth as a result of associated angiogenesis, cytokine and growth factors release.

CASE PRESENTATION

We describe a patient with non-small lung cancer who had a rapid tumor growth and recurrence at a minor trauma site of his skull bone.

CONCLUSION

This case is an illustration of the phenomenon of tumor growth after trauma or surgery and its associated cellular mechanisms. This phenomenon deserves further investigation and study.

Inflammatory breast cancer in a male

Male breast cancer is very rare, especially inflammatory breast cancer, which is an aggressive, rapidly proliferating manifestation of primary breast carcinoma. We present a case report of a 56-year-old man in Lebanon who died 8 months after being diagnosed with inflammatory breast cancer.

Docetaxel extravasation into the normal breast during breast cancer treatment

We report a new case of central line extravasation of docetaxel into the normal breast of a patient with metastatic left breast cancer. During the infusion of docetaxel, the patient complained of mild discomfort at the site of a subclavian Port-a-Cath, followed by redness, warmth and itchiness of the entire skin of the right breast beneath the port of entry, and it involved the entire right breast by the next day. Over the following few days, she developed blistering, desquamation and oozing of serous fluid through skin fissures. Anti-histamines and hydrocortisonebased ointment induced partial relief of symptoms. Warm soaks induced skin relief. Reaction resolved over few weeks leaving a brownish pigmentation of the skin of the breast, with clearly demarcated lines, as the only sequlae.