Breast cancers remain the most feared by women and rightly so: with around a third of diagnosed cancer cases, they are the most common and responsible for 20% of female cancer-related deaths. Figures which explain that for decades, when faced with this disease, the strategy was to “hit hard” without delay to put all the chances on the patient’s side. Since then, many parameters have evolved, including knowledge of tumor biology, diagnostic tools and treatments, so that today 90% of patients are alive five years after diagnosis. New treatments allow for better personalization of treatments, with a more targeted approach, often a de-escalation of care and less negative impact on patients’ quality of life.
Do not neglect the social dimension
Scientists from the University of Geneva (UNIGE), HUG and, in France, the National Institute of Health and Medical Research and the Gustave Roussy Institute followed 5,900 patients with breast cancer early and having had access to similar treatments, in order to assess the weight of socio-economic inequalities on their quality of life. A score was thus established: while at the time of diagnosis it was already 6.7 between the two socio-economic extremes (a score of 0 indicating the absence of inequalities), it rose to 11 during treatment, to remain at 10 two years later, these figures showing the worsening of inequalities due to the disease. The women in this cohort were treated in France, “a country that is nevertheless very egalitarian in terms of access to care,” emphasize the researchers. Before adding: “When we talk about precision oncology, we should take into account the person as a whole, including their social dimension.”
“The management of breast cancer in particular has been a pioneer in the personalization of treatments, adapting them to the type of tumor,” recalls Dr. Anita Wolfer, head of the Breast Center at the University Hospitals of Geneva (HUG). Talking about breast cancer is indeed a shortcut. And for good reason, there are different types whose specificities guide the therapeutic choice. The most common cancer, which represents nearly 75% of cases, is called “hormonosensitive”. It is so called because the tumor has estrogen or progesterone receptors. Other cancers – hormone sensitive or not – are called “HER2 positive” because the tumor expresses a particular receptor called HER2. Finally, cancers with poorer prognoses are “triple negative”, which do not have receptors for estrogen, progesterone or HER2.
Targeted therapies
One of the major therapeutic advances in recent years has been the development of targeted therapies against HER2. “It was a game changer! Until now, the presence of HER2 receptors had a rather poor prognosis, whereas now this makes it possible to use these new treatments which have very good effectiveness,” explains Anita Wolfer. Other good news: very recently, the therapeutic arsenal against triple negative cancers has also been expanded. Results presented in September at the annual congress of the European Society for Medical Oncology (ESMO) confirmed the interest in immunotherapy, a therapy that leverages the immune system to fight the tumor. “The use of certain so-called “anti-PD1” antibodies in addition to standard chemotherapy before surgery significantly increases the chances that the tumor will have completely regressed before the operation. And this is an excellent prognosis,” explains Dr Khalil Zaman, medical manager of the Breast Center at the Vaud University Hospital Center (CHUV).
The treatment pathway for hormone-sensitive cancers, which are more easily treated, has also evolved. “It always involves surgery, but mastectomy is not systematic. If cancer is diagnosed during screening, for example, it is only performed in 15 to 20% of cases, emphasizes Dr. Wolfer. “And we are also more conservative about lymph nodes, when possible, which reduces the risk of lymphedema, also called ‘big arm syndrome’.” Radiotherapy techniques have also progressed, and a study presented at ESMO confirms that for a large proportion of patients, it would be possible to reduce the number of sessions necessary over three weeks to fifteen, instead of twenty-five over five. weeks today. In this type of cancer, antihormonal therapy, or hormone therapy, which mimics menopause is often prescribed for five to ten years.
Impact on quality of life
Although new antihormonal therapy options have also appeared in recent years, the impact of their side effects on quality of life often remains significant. “I recently hosted a coffee meeting with patients: only two of them indicated that their treatment did not pose a problem,” relates Patricia Magnin, referring nurse at the Friborg Breast Center. Most often, the question of side effects generates major discomfort for women and they struggle to discuss it with their oncologist.
It is estimated that more than a third of patients stop their treatment because of these adverse effects. “It is up to us, doctors, to establish dialogue on these subjects. For example, it can be difficult for patients to spontaneously talk about a problem with vaginal dryness when the treatment is there to limit the risk of cancer recurrence. But we have options to offer them, emphasizes Dr. Zaman. The majority of patients have many years of life ahead of them, which must be of the best possible quality. These women should not have to choose between their daily lives and following their treatment.”
The crucial role of referent nurses
The reference nurses who work in the French-speaking Breast Centers are essential links in the chain of care for women with cancer. If the first certified nurses, also called BCN (for Breast Cancer Nurse), came into operation only around ten years ago in Switzerland, their specifications are vast. “We intervene as soon as the diagnosis is announced, where we ensure that the patient has assimilated all the information transmitted by the oncologist,” explains Patricia Magnin, who works at the Friborg Breast Center. And to specify: “We take stock of her needs, expectations and quality of life objectives and are present at each stage of her journey, whenever she wishes. We can discuss the adverse effects of treatments as well as inform her about auxiliary means (wigs, scarves, external prostheses, etc.), or put her in touch with other support professions, from social workers to dieticians, including support and discussion groups. Our great strength is the time we can take to interact with her.”
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Published in Le Matin Dimanche on 06/10/2024
