REVIEW ONCOLOGY

Early detection and diagnosis of prostate cancer in well informed men: the way forward for Europe

SUMMARY

As 107,000 men died of prostate cancer in Europe in 2018, this is not an indolent disease. It is responsible for >10% of all male cancer deaths. Most men are not aware that it is possible to have asymptomatic prostate cancer and are uninformed about the existence and value of the PSA blood test. Early detection of prostate cancer reduces the mortality rate and can be easily cured without unbearable side effects and at a rather low price. Advanced cancer is less amenable for cure, with substantial side effects and a significant reduction in quality of life, and has a high chance of becoming metastatic and castrate-resistant. Treatment of this late stage disease is costly and prolongs life with on average only two years. Most importantly, the quality of life of these men is poor. The arguments against PSA testing are focused on issues related to over-diagnosis and overtreatment. These arguments have led in some countries to a decrease in testing, which in turn has led to an increase in too late diagnosis. In this paper, we present the results of clinical trials on early detection, the risks and benefits of early detection using PSA testing, and a way forward for the EU Cancer Plan using the current EAU scientific guidance on early detection as a basis. We conclude that PSA can now be used in a more clever fashion to ensure that men are diagnosed early enough to be able to prevent meaningful clinical disease, increase quality of life, and reduce costs for healthcare systems.

(BELG J MED ONCOL 2020;14(7):321-6)

Lessons learned after two decades of international academic clinical research in breast cancer: 2019 JC Heuson Memorial Lecture

SUMMARY

The Breast International Group (BIG), founded in 1999, is the umbrella organisation harnessing the efforts and supporting the activities of its nearly 60 national and international cooperative group members worldwide. BIG’s collaborative research model provides academic leadership in industry-sponsored randomised clinical trials. Some of these trials have successfully led to the rapid registration of new anticancer drugs with a significant impact on breast cancer mortality, such as the HERA trial, which contributed to the registration of adjuvant trastuzumab in many countries around the world in less than four years. BIG also supports clinical trials sponsored by its academic member groups and facilitates collaboration between international researchers and the US cooperative groups: the SOFT and TEXT trials evaluating adjuvant endocrine therapies for 5,738 premenopausal women are an example of such a collaboration, which has helped clarify which women can be safely treated with tamoxifen and which women are best served by a combination of tamoxifen or an aromatase inhibitor with an LHRH agonist. BIG is most proud of its ambitious purely ‘academic’ initiatives: namely MINDACT and AURORA.

MINDACT, which was recently updated at a median follow-up of 8.7 years on its 6,693 enrolled patients, most of whom had hormone receptor positive/HER2 negative (HR+ HER2−) early breast cancer, continues to demonstrate the clinical utility of a low risk 70 gene signature for foregoing adjuvant chemotherapy in the presence of a high clinical risk (and no more than three positive nodes) in women older than 50 years. In younger women, a clinically relevant chemotherapy benefit of about 5% has emerged and should be part of informed shared decision-making. AURORA is an ongoing European effort at elucidating the clonal evolution of breast cancer towards the development of lethal metastasis: with close to 1,000 women with metastatic breast cancer already enrolled, it aims at the integration of multiple genomic analyses with high quality clinical data, longitudinal sampling and a biobank. Its impact could be improved treatment strategies and personalisation in the years to come.

(BELG J MED ONCOL 2020;14(7):327-32)

Management of Mucinous Ovarian Cancer in 2020: literature survey

SUMMARY

In this article the authors reviewed literature regarding mucinous ovarian carcinoma (MOC), which represents a special challenge as a rare ovarian tumour (about 3%) with unique clinical characteristics as compared to serous ovarian carcinoma (SOC). MOC is mostly diagnosed at an early stage and is generally associated with an excellent prognosis. However, later stages usually remain resistant to medical treatment, with early deaths occurring. Overall, advanced MOC patients seem 2.3 times more likely to die of their tumour as compared to SOC patients. Anatomo-pathological diagnosis and distinguishing between primary and metastasised MOC remains difficult and sometimes inconclusive, despite the contribution of immunohistochemistry (IHC) and/or molecular biology. The preservation of fertility is currently conceivable in younger patients with an early stage disease.

(BELG J MED ONCOL 2020;14(6):246-53)

Locally advanced rectal cancer: What is the best perioperative strategy?

SUMMARY

The treatment for locally advanced rectal cancer involves a multidisciplinary approach in which total mesorectal excision usually is preceeded by (chemo)radiotherapy. Depending on risk factors, adjuvant chemotherapy is frequently applied. Preoperative short course radiotherapy and chemoradiotherapy result in high local control rates. However, the high risk on systemic relapse and the appealing concept of organ preservation urge researchers to explore alternative perioperative strategies. This review provides an overview of the established role of preoperative short course radiotherapy and chemoradiotherapy, as well as the evidence so far for short course radiotherapy with delayed surgery, induction chemotherapy and for neoadjuvant chemotherapy without radiotherapy.

(BELG J MED ONCOL 2020;14(6):254-62)

Incidence of breast cancer subtypes in Belgium: a population-based study

SUMMARY

The aim of this study is to provide a reference for the Belgian breast cancer population, offering detailed information on various patient and tumour characteristics for the breast cancer population as a whole, as well as for the different molecular subtypes. Incidence data for primary invasive breast cancer in females diagnosed in 2014 were selected in the Belgian cancer registration database and underwent individual manual reviewing of the pathology protocols. Subsequently, in 95% of the study population a surrogate molecular subtype was successfully derived, using the combined expression of oestrogen receptor, progesterone receptor, human epidermal growth factor receptor-2, and tumour differentiation grade as surrogate for the proliferation marker Ki67, in conformity with the 2011 St Gallen surrogate classification. Ultimately, differences between the molecular subtypes regarding initial presentation and histopathological features were evaluated by means of a Pearson Chi-squared test for independence. Furthermore, relative survival was calculated for the different molecular subtypes. Histologically, the large majority of the Belgian breast cancer population presents with invasive breast carcinoma of no special type (NST), formerly called invasive ductal carcinoma (75.2%), 14.5% with invasive lobular carcinoma and 5.8% with mixed ductal/lobular invasive carcinoma. Less than five percent of the population harbours less frequently occurring histological subtypes. The Belgian breast cancers are predominantly of the luminal A-like subtype (54.4%), followed by the luminal B-like HER2 negative (14.7%) and the luminal B-like HER2 positive subtype (12.2%). The mean age at diagnosis is 62 years, with almost a third of the patients being 70 years or older. One out of five patients is younger than 50 years, and in the triple negative population this group counts for 31.9%, compared to 16.6% in the luminal A-like breast carcinomas. Most patients (69.4%) are diagnosed with early stage breast cancer (clinical stage 0-II); six percent of the breast cancers are clinically metastasised at the time of diagnosis. For 19% of the patients, information on clinical stage was lacking or staging was not applicable. The unadjusted five-year relative survival proportion for the Belgian cohort is 91.4%. Luminal A-like breast cancer opposed to triple negative breast cancer have the best and worst relative survival, with respectively 96.8% and 77.4% five-year relative survival proportions.

(BELG J MED ONCOL 2020;14(6):263-73)

Partial breast irradiation of early-stage breast cancer

SUMMARY

Whole-breast irradiation, as part of breast-conservation therapy (BCT), has been well-established the last decades. Nonetheless, most local recurrences found after BCT are within or close to the tumour bed. This led to the concept of partial breast irradiation (PBI), delivering the radiation dose to a decreased target volume, thereby lowering exposure to the organs at risk and hence potentially minimizing late adverse effects. This became increasingly important with growing survivorship of patients with early-stage breast cancer over the past decades and the consideration of late adverse effects is gaining more importance. In this review, we will present an overview of the current literature, techniques to deliver PBI and we try to establish whether there is a place for PBI in early-stage breast cancer treatment.

(BELG J MED ONCOL 2020;14(4):140–45)

The advanced practice nurse (APN) in oncology: an opportunity to meet the fast evolving needs in cancer care

SUMMARY

Cancer nursing is a profession in full development. In oncology, as well as in other domains, nursing roles have evolved substantially to better meet patients’ needs and expectations, the complexity of evidence-based (nursing) practice and to better fit needs related to quickly evolving oncology treatments and services. The recognition of advanced practice nurses (APN) in the Belgian legislation in 2019 may further stimulate the implementation of advanced practice nursing in interdisciplinary care, and in oncology in particular. APN have completed a master’s degree as well as additional education and training in a specific clinical domain, such as oncology. The core competencies of APN are clinical practice; expert coaching and guidance; consultation; collaboration; improvement of quality care and innovation; leadership; research and ethical decision-making. APN share a care-oriented focus and person-centred approach. Besides their role in direct clinical practice, APN create an added value in quality improvement, innovation and implementation of evidence-based nursing practice. Therefore, APN closely collaborate with nursing staff, medical staff, other healthcare professionals, management and stakeholders.

(BELG J MED ONCOL 2020;14(3):93–9)