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Current Opinion in Supportive & Palliative Care:
doi: 10.1097/SPC.0000000000000028

Treatment for locally advanced breast cancer: a global challenge, personalized medicine or both?

Jacobs, Carmel; Simos, Demetrios; Clemons, Mark

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Division of Medical Oncology, The Ottawa Hospital Cancer Centre, University of Ottawa and The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada

Correspondence to Mark Clemons, MD, Division of Medical Oncology, The Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada. Tel: +1 613 737 7700 x 70170; fax: +1 613 247-3511; e-mail:

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In this special issue of Current Opinion in Supportive and Palliative Care, we are delighted to bring together key, internationally recognized experts in the field of breast cancer care for a special issue on locally advanced breast cancer (LABC). To place this disease in context, we have deliberately tried to keep the chapter headings pertinent to the real world issues facing both patients and their healthcare providers.

We, therefore, start with some practical definitions of what actually constitutes a diagnosis of LABC. Although neoadjuvant systemic therapy has become increasingly popular over the last decade, the reality is that relatively few of these patients have inoperable disease. It is challenging, therefore, to extrapolate findings from most neoadjuvant studies into the LABC population. Clearly, more trials dedicated to LABC patients are needed. Although not the most common presentation of breast cancer in North America, LABC continues to represent a challenging scenario for patients and healthcare professionals alike. By definition, LABC represents more advanced disease relative to earlier stage breast cancer and is not only associated with significant local and systemic complications but also with complex patient-related psychosocial issues [1]. It is these compounding threats that demand an integrated, multidisciplinary approach to achieve the best possible outcomes for patients. Vivid prose outlining the consequences of untreated LABC, found in a seminal article by Bloom et al.[2] summarizes this threat with astonishing accuracy and can be found in the first accompanying article.

Unfortunately, the ‘foul and ulcerating’ tumours described in the aforementioned article are still seen today, in fact with the increasing incidence of LABC in the developing world, it may be one of the most pertinent issues we as healthcare professionals are facing [3]. In the developing world and in societies with limited access to modern screening and treatments, the morbidity associated with LABC is growing [4,5]. Attempts to recognize and manage the forecast increasing rates of advanced cancer in societies where improved sanitation and infection control have lead to rapid changes in population demographics have resulted in LABC becoming an increasing global health issue. We are, therefore, grateful for the insight provided by a world recognized expert in this field, Ophira Ginsburg, in her comments on why global health issues are so important to all of us.

With respect to management issues, we are pleased to bring together expertise from a multidisciplinary panel. Angel Arnaout et al. discuss the challenges facing surgical oncologists in the management of LABC including a discussion on appropriate surgical options, timing of surgery and controversies surrounding how best to assess the breast [6]. Issues relating to radiation oncology being explored in the LABC population are presented by Jacqueline Spayne and Justin Lee [7].

Systemic therapy is covered in three separate articles focusing in turn on standard systemic therapy, novel targeted therapy and endocrine therapy. Nowadays, primary systemic therapy is often considered the optimal approach for a LABC. The approach is appealing with benefits, such as potentially downsizing the primary tumour to facilitate removal, in-vivo assessment of treatment response and increasingly as a source of tissue for correlative studies of tumour sensitivity and resistance to treatment [8,9]. Given that patient outcomes in terms of disease free and overall survival appear equivalent whether treatment is given preoperatively or postoperatively, there is little doubt we will continue to see ongoing interest in neoadjuvant therapy [10,11]. But what is the optimal systemic therapy? This question along with that of response-guided therapy and the meaning of a pathological complete response is covered in the article by Susan Dent and Rebecca Dent. Stephen Chia et al. discuss novel agents, and how increasingly they are being utilized and assessed in the neoadjuvant setting. The HER-2 (human epidermal growth factor receptor 2) story of adjuvant therapy will be well known to many, the role of anti-HER-2 directed therapy including combined blockade in the neoadjuvant setting is one of many exciting new strategies discussed.

As oncologic management moves towards a new era of personalized medicine, we are beginning to appreciate that chemotherapy is likely not the best treatment for many patients. In this context, the article by John Hilton is important, as he discusses the role of primary endocrine therapy as a valuable treatment option in the neoadjuvant setting. As our population ages, the prevalence of concurrent comorbidities limiting traditional systemic therapy options is increasing, so it is not unreasonable to assume we will be looking at using more endocrine therapy rather than traditional cytotoxic approaches. This approach may also be increasingly utilized in lower grade and Luminal A breast cancer subtypes [12]. Can endocrine therapy be a more effective neoadjuvant therapy than chemotherapy? Is it a more affordable yet valid option for those to whom more expensive therapy is not available? Are there patients who do not benefit from chemotherapy and should be solely treated with hormonal therapy? Time will tell.

These controversies surrounding therapy are addressed by various authors in the accompanying reviews in this special issue of the journal. In many clinical scenarios, answers to our questions are not yet available, but hopefully well planned future clinical research will shed light on some of the questions that urgently need answers. As more information becomes apparent, a ‘one size fits all’ approach in LABC is likely to be supplanted by a more ‘personalized’ approach that takes into consideration both individual tumour and personal characteristics in an attempt to tailor the most effective therapy to a specific patient.

The contribution by Christine Simmons et al. ushers us into the modern era as they touch upon the role of social media, and how they play a role in standardizing care for locally advanced breast cancer. Breast cancer has massive public awareness. There are countless charities, foundations and support groups devoted to bettering patient outcomes and supporting the millions of women with this disease. Through the role of social media, enhancing communication between both healthcare providers and patients themselves and encouraging earlier contact with medical services [13] can lead to improving outcomes as demonstrated in the accompanying article. We are certain that the role of social media will no doubt play an increasing role in facilitating the global management of breast cancer.

Last but not least, we should not forget about supportive and adjunctive care for this disease [14]. In this light, Gini Jarvis, a palliative nurse specialist, has highlighted some of the palliative care issues frequently encountered by members of her team at a large Canadian academic cancer centre. Disease control, wound management, pain management, psychological support, maintaining quality of life and holistic care for the woman who is no longer deemed ‘curable’ is of equal, if not greater, importance as defining the optimal neoadjuvant therapeutic strategy. Although the ultimate goal is to eradicate the above scenario, for the individual patient, optimizing palliative care, incorporating a multidisciplinary approach so commonly used in the curative setting, providing comfort, dignity and quality of life, is a universal goal.

We hope that our readers enjoy this special edition of Current Opinion in Supportive and Palliative Care. We have chosen to include some oft neglected topics surrounding the management of LABC, but hope in doing so we have encompassed universal issues relevant to all.

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Conflicts of interest

Funding sources: None.

All authors declare that they do not have any potential conflicts of interest relating to the work presented in this article.

All authors have seen, reviewed and approved this article.

All authors have completed and signed copyright transfer forms, and these have been included with the article submission.

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