Health and Culture Quarterly • ONCOLOGY
WITH CONSULTANCY INPUT FROM:
DR. Gianluca FOGAZZI
ISTITUTO CLINICO S. ANNA (BS)
It affects one in 8 women, and is the most common female cancer, with an incidence of 29 percent. We are talking about mammary carcinoma. It can be invasive or non-invasive (in situ), and it develops in four stages. The chances of recovery are very high if it is diagnosed during its initial phase by means of mammography or mammary echography. In addition to prevention, it is essential to pay the utmost attention to the main risk factors: mutations in DNA genes passed on to family members, late pregnancy or no pregnancy, not having breast-fed, early menstrual development and late menopause. Maintaining a healthy lifestyle is also essential.
Doctor Fogazzi, what is your experience with regard to the health of the female population?
“Our contact with patients relates to mammary pathology in 60-70% of cases. Our observations therefore derive mainly from this type of approach to the female population and because mammary tumours have peculiarities that other pathologies do not have. For example, 360-degree treatment of a patient is becoming ever more structured and defined, with a multi-disciplinary approach and assistance with post-tumoral care wherein it is appropriate to provide guidance for women following the check-ups that they should undergo periodically.”
Give us an example.
“Adjuvant treatments, therapies administered after surgical intervention aimed at reducing the risk of recurrence are extremely important (in a recent United States case study, they appeared to account for a 60 percent reduction in mortality). However, it is essential to know how to best manage all of the various toxicities resulting from the treatments, in order to prevent any long-term side effects, as well as assisting younger women if they wish to embark on a pregnancy following a cancer diagnosis. But not just this. Another aspect that is not as limited as might be thought is the assessment of patients at high risk because of hereditary family syndromal factors: to be clear, these are women with a mutated BRCA gene, in the majority of cases.”
What precautions should women take with regard to prevention?
“In order to answer this question, a distinction needs to be made: there are women with a “normal” risk and patients who have an “increased” risk because of pre-disposing family factors. In the first case, for those below 40 years of age, there are no particular examinations to be undergone, although broadening the sample of women who should undergo screening is becoming a topic for debate. Within our Region, invitations have been issued to date to women in their fifties, but the average age is probably more like 45 years. And it should be specified in any case that, if anyone discovers a lump during self-palpation, they should never under-estimate it, but in fact should inform their referring doctor, in order to arrange a possible echo-mammographic check.”
I imagine that there is another protocol for patients with a family history of breast cancer, is there not?
“A further distinction needs to be made among woman with a family history of breast cancer: there are those who have a family history, and thus a recurrence, of it, without there necessarily being a genetic predisposition behind this, and there are those who present a clear risk factor. Until recently, many women did not know in which of these two situations they were, as tests were very uncommon, and reserved for very specific conditions. Today, thanks to the advent of multi-disciplinary teams, when factors indicated by the guidelines are present, genetic counselling and a possible test tend to be suggested. This means that family members of patients with mutations can also be reviewed, by undergoing checks aimed at ruling out underlying genetic mutations.”
What is your approach for patients with a clear genetic predisposition?
“It ranges from more interventional, with prophylactic surgical interventions, to dedicated follow-up with much more targeted and in-depth instrumental analyses.”
The surgical removal of a breast probably represents the most delicate transition within the entire therapeutic process. How do you succeed in dealing with patients’ psychological and aesthetic requirements?
“If it is necessary to have recourse to mastectomy, and thus a destructive intervention, our surgeons are able to offer patients reconstruction that provides a good result from both an aesthetic and functional point of view. A significant fact: in a good six out of ten cases, the patient undergoes immediate reconstruction during the initial surgical intervention.”
In recent decades, great strides have been made within the area of tumours, especially for breast neoplasms, there is now a great chance of complete recovery. Is this true?
“Absolutely. Taking all stages into consideration, from the earliest to the most challenging phases, I would say that a woman has an eight out of ten probability of recovery.”
With regard to this possibility, can a woman who has overcome breast cancer go back to her old life?
“Over the last few years, two somewhat prejudicial clichés have been repudiated: the first relating to a fear of treatments carried out possibly impacting on the health of any unborn child, and the second that any pregnancy could aggravate the prognosis and the course of the breast cancer. On both counts, reliable and mostly reassuring data has come to light ‒ very low risk to an unborn child, and no difference in prognosis among patients who are expecting and who have had a mammary tumour operated upon, including those who present hormone-responsive tumours.”
What treatment does a woman who discovers breast cancer usually have to undergo?
“If we are talking about initial-phase cancer, the available treatments, used on the basis of whether they involve a high or low risk of recurrence, include chemotherapy, hormone therapy, and treatment with monoclonal antibodies. Additionally, appropriate local treatment, i.e. surgical intervention and radiotherapy. However, in cases of full-blown and inoperable tumours, there are ,in addition to the drugs already listed, some new-generation ones that potentiate the action of hormone therapy, like for example cyclin-dependent kinase inhibiting drugs, with an extremely high tolerability profile, and efficacy that is at least comparable to that of chemotherapy.”
For the treatment of breast cancer, the Istituto Clinico S. Anna can boast with a Breast Unit that has been active for many years, and has been EUSOMA certified since 2015. How important is it for a woman preparing to face this “battle” to rely on a structure that can ensure a multi-disciplinary approach?
“Very much so, and two elements demonstrate this in particular: on the one hand, the co-existence of different specialists working within a multi-disciplinary team ensures quality of care, timeliness, the exchange of views, a gradually defined common line, and, not least, an 18 percent reduction in mortality risk. On the other hand, a more psychological component, but no less important for this: a feeling of one’s hand being held, of being accompanied along the way and guided, without feeling abandoned or disoriented in any way, are equally important aspects for a woman.”
THE BREAST UNIT AT ISTITUTO CLINICO S. ANNA
The Breast Unit at the Istituto Clinico Sant’Anna in Brescia has been active for many years – a specialist multi-functional unit, led by Doctor Fabrizio Palmieri, within which all of the structures and services that contribute to the treatment of patients with a mammary pathology, in all phases of the hospital journey, operate and collaborate: from diagnosis to treatment to follow-up (editor’s note: “periodic check-ups”). Thanks to the constant interaction between specialists linked to different fields of medicine (oncologist, surgeon, radiotherapist, physical therapist, psychologist, geneticist, plastic surgeon, radiologist, pathologist and nurse), in 2015 the Gruppo San Donato’s Breast Unit was awarded Breast Centres Certification, the prestigious European quality certification that attests to adherence to the guidelines for the treatment of breast cancer recommended by EUSOMA (European Society of Breast Cancer Specialists). The multi-disciplinary approach, together with the effective application of the recommended guidelines and pathways (a guarantee of excellence) and quality of performance make the Breast Unit a landmark for all those patients with oncological pathologies who need personalised and cutting-edge treatment, and viable 360-degree assistance.
Objectives achieved in 2017:
- Tumoral lesions operated: 282
- Carcinomas in situ: 45 (16%)
- Invasive carcinomas: 237 (84%)
- Conservative interventions: 70%
By: Tommaso Revera
Translation: TDR Translation Company
Editing: Victor Cojocaru