Intermediate breast cancer two different treatment approaches

Author: 
Anil Kumar B., Rehman M.M and Kalyan, K.A.S.S.N

Introduction: Breast cancer is one of the commonest malignancies affecting female population all over the world hence standard and universally acceptable treatment strategies are necessary for management
Objectives:
1. To study the impact of neo-adjuvant chemotherapy on local and regional control as well as the disease free and overall survival in T 3 breast cancer.
2. To compare the impact of two different modalities of management, namely pre- operative (neo adjuvant) and postoperative (after primary surgery) adjuvant chemotherapy on outcomes in this intermediate group of breast cancers.
Methodology: Cohort study in a Department of general surgery, Tertiary care teaching Hospital
Sample selection: All cancers of the breast belonging to T3N1M0 and T3N0M0 were grouped together into a category named Intermediate breast cancers. All untreated intermediate breast cancer patients reporting to Dept. of Surgery, Tertiary Care Teaching Hospital between 18 and 85 years of age and willing to provide a written informed consent were recruited into the study. All terminally ill patients, patients who have previously received any form of definitive treatment (surgery/ chemotherapy/ radiotherapy), patients with co-morbidities and patients with poor cardiac function were excluded from the study.
Patients receiving neo adjuvant chemotherapy followed by Surgery formed the exposed group and patients undergoing primary Surgery followed by complete course of chemotherapy formed the unexposed group. Data collection and analysis was done using a specially designed detailed individual case record. The data were entered in Microsoft Excel 2007 and analysed using SPSS 17.0.
Results: Participants ranged from 25 to 85 years age. Early menarche was seen in 14.1 percent of women and late menarche in 9.4 percent. Of the 128 women who participated in the study, 25 percent belonged to the T3N0M0 category and the rest to the T3N1M0 category. Majority of participants were found to have Grade I or Il disease. Immunohistochemistry analysis showed that 39.1 percent cases were negative for all three receptors. The impact of neo adjuvant chemotherapy was assessed after three courses uniformly in all cases. Clinical response was defined using the criteria laid down by the World Health Organisation. Analysis showed that neo adjuvant chemotherapy had a significant positive impact on the clinical as well as pathological response. This positive impact persisted even after adjusting for possible confounders such as age, menopausal status, TNM staging and grading of the tumours as well as the time difference in initiating definitive treatment. Assessment of pathological response after surgery conclusively showed that there was a significant reduction in tumour size in patients who underwent neo adjuvant chemotherapy. The follow up period of six months was too short to study disease free survival as well as overall survival rates.
Conclusion: This cohort study showed that neo adjuvant chemotherapy had a significant positive impact on local control of breast cancers. This should result in modification of treatment protocols with an aim of promoting breast conservation surgery to a greater extent. Conservation of breast can have a highly positive impact on the morale of the women undergoing treatment. There is a need to develop a well defined protocol for deciding between NAC and primary surgery in case of Intermediate breast cancers (T3N0M0 and T3N1M0) and the group needs to be followed up for longer period to obtain clear evidence of benefits of neo adjuvant chemotherapy in long term and disease free survival.

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