By the end of this year, Spain will have diagnosed some 35,000 new cases of breast cancer, according to estimates by the Spanish Society of Medical Oncology (SEOM) in its report “Cancer figures 2022”. Of this figure, the majority will be in the early stage, but despite this, one in five people will suffer a relapse throughout their lives. Despite the science, the advances and the cure figures reach more than 90%, breast cancer can come back in some women. For this reason – and a few days before the International Day Against Breast Cancer is celebrated on October 19 – Lilly has launched, with the support of the Spanish Federation of Breast Cancer (FECMA), the “Count on You” initiative with the objective of promoting knowledge, training and self-care so that people with breast cancer at risk of recurrence face this situation in the best possible condition. An initiative that wants to convey a clear message: “In the face of breast cancer, the first support is yourself.”
And to delve into it, the ABC Health Forum addressed the characteristics of patients with higher risk of relapse, the advances in research with curative intent, the need for an active dialogue between the patient and the health professional to facilitate adherence to long-term treatments or knowledge about their effects most common side effects and how to manage them. To do this, nothing like the expert opinion of Professor Ramon Colomer, head of the Medical Oncology Service at La Princesa University Hospital; by María José Lallena, director of the Lilly Spain R&D Center, and the direct testimony of Ana Valderas, a breast cancer patient. They all agreed that it is important to adherence to treatments long term and the research progress in this field, so that these patients can enjoy life with the best possible quality.
More than 90% of people diagnosed with breast cancer are in the early stages, with a localized or regional tumor, without it having spread outside the breast or the lymph nodes in the armpit. «The usual thing, despite reporting breast cancer, is to give good news and explain that the prognosis is good. 20% of operated cases have a relapse throughout their lives. But, even in cases of poor prognosis there is hope, we have treatments that can help prevent relapse in patients where it is necessary”, explains Dr. Colomer, who assures that this is part of the path of individualized and precision oncology, in which each case is studied and a roadmap is planned for each patient.
Damocles syndrome
Ana Valderas knows well what it is to live in fear of a relapse. Although she has been there for almost 30 years, she does not forget the moment when they gave her the news. «She was 36 years old and had three children. The youngest still had a pacifier and when they told me that he had breast cancer I couldn’t believe it. The world falls on you and you think that you are not going to see them grow up anymore. And here I am, luckily I have not suffered a relapse, but I have shared the situation of many other women and there is not a day in my life that I do not think about it. The sword of Damocles syndrome that we all have is brutal. There is not a day that we do not feel it, there is not a moment that we do not think about it. But today we have a powerful weapon such as training, knowledge, empathy with professionals and we know that, thanks to research and innovation, everything is in our favor. It has nothing to do with 30 years ago where, for example, where I lived there was no oncology ». For this reason, she has been defending the creation of patient associations such as those that are part of FECMA (the case of Santa Águeda, in her native Puertollano) to help improve the quality of life of cancer patients.
During the debate, the importance of breast cancer research was made clear
Colomer gives good faith of the progress made in these three decades. Before the beginning of the 21st century, it was thought that breast cancer was differentiated by its origin: from cells that belong to the ducts of the mammary gland (ductal carcinoma), from cells that belong to the lobules of the mammary gland (lobular carcinoma ) or cells from the most distant areas of the gland (basal carcinomas, claudin low, sarcomas…). Since 2002 and after reading the human genome, it was discovered that not all breast cancer cells that came from the same area of the gland expressed their genome in the same way. What allowed to describe different groups within each type of breast cancer. These expression factors also indicate a different prognosis, which is why it was decided to classify breast cancer according to what its cells expressed.
Thus, the molecular classification of breast cancer was divided into tumor cells that express hormone receptors (RH) and those that do not; and those that express a family of proteins on the cell surface called HER-2 and those that don’t. This HER-2 gives tumor cells a greater ability to divide, so that if it is present together with HR, the tumor cell has more options to spread. breast tumors RH+ y HER2-, which are the majority of cases, are called luminal, they are the ones that respond very well to hormonal treatment and have the best prognosis. In contrast, breast tumors without hormone receptors have a worse prognosis.
“The high risk of relapse occurs in those tumors that after their operation and removal have a high probability of reappearing at a distance, in the form of metastasis, which more likely leads to an unfavorable evolution, or locally in the operated breast,” he points out. Colomer. Today it is known that there are certain clinical or pathological characteristics that are associated with a higher rate of recurrence and a worse prognosis, so it is important to identify who these patients are. Some of these characteristics that indicate a increased chance of relapse or recurrence are a greater number of affected nodes, a large tumor size, aggressiveness in the cells or high cell division. All these characteristics imply a relatively high possibility of relapse, around 30%, and, as they are known at the beginning of the disease, they allow personalized treatment planning.
Adherence to treatment
“Patients with localized breast cancer after surgery, if they are at risk of recurrence, receive personalized treatment. Adherence to long-term treatment after surgery is essential to obtain the maximum benefit for patients. We must always try to avoid relapse and now we have treatments that we did not have five years ago, “explains Dr. Colomer.
Determining the high risk of relapse of a person with early-stage breast cancer will allow establishing the type of long-term adjuvant treatment. And it is that, despite advances in the treatment of breast cancer, between 20 and 30% of patients in early stages experience relapses and between 12 and 14% of women with breast cancer in early stages luminal, with RH+ die within ten years. Therefore, choosing a treatment that reduces the probability of relapse or is even capable of making it disappear is essential. Usually the treatment after surgery is hormonal (since most tumors will be luminal, with RH) and can last for several years, from five years to ten years. Adding the long-term use of these adjuvant treatments has a curative intent. However, the main difficulty for long-term adherence lies in the toxicities that these treatments can produce. “They may be more acceptable if they are reversible, predictable and manageable or treatable. Today we have a whole battery of treatments that can be modified depending on how it affects the patient”, explains Colomer.
Ana Valderas acknowledges that it has been difficult for her to accept that she will be a patient for life and expresses her peculiar vision: “I am a healthy woman being patient.” Of course, she makes clear the importance of “making women aware that they cannot stop treatment due to many adverse effects they have. It cannot be abandoned, we have to be constant and follow the medical prescription because it is a matter of life »and she insists on the importance of women attending their check-ups and having mammograms.
Research and innovation
And for these treatments to be the most innovative and best possible, research plays a key role. “We have been working for more than 35 years to develop medicines that help improve people’s lives,” explains María José Lallena, director of the Lilly Spain R&D Center. In 2021 Lilly spent $7 billion on R&D, which translates to $28 million a day globally. In Spain, investment stood at 56.3 million. “Investment is important and there is no need to put a ceiling on it, but we must reinforce the ecosystem that we are creating between private companies, clinics and academia. That research triangle where each of us contributes the best we know to speed up the development of new drugs.” In this sense, Colomer agreed that «breast cancer research in Spain has an excellent level. Unlike other countries, there are cooperative groups that are promoting the most advanced treatments in breast cancer, and this makes our position very good and internationally recognized”.
Advanced treatments for which this Spanish R&D center has received the prestigious “Heroes of Chemistry” award from the American Chemical Society (ACS), which recognizes those researchers and companies for the development of medicines that have given rise to Significant advances in health and medicine. Specifically, thanks to his contributions in breast cancer. An example of the commitment that the scientific and research community has in Spain with this pathology. Because if the three speakers agreed on something during the meeting, it is that thanks to research and innovation every day it is closer that breast cancer is just a chronic disease.