During the second day of the ‘First Ibero-American Breast Cancer Meeting’ (Eiboma), which takes place at the Luis Carlos Sarmiento Angulo Cancer Treatment and Research Center (CTIC), experts from several countries have shared their knowledge about the latest and most innovative oncological advances.
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Miguel Martín, international breast cancer oncologist and head of the Medical Oncology Service at the Gregorio Marañón Hospital, a public center in the Community of Madrid, participated in the panel on the management of hormone therapy for patients with this type of cancer.
In an interview with EL TIEMPO, the Spanish doctor spoke about the effectiveness of this treatment and the benefits of exercise and diet in the lives of patients.
What is adjuvant endocrine therapy?
Adjuvant endocrine therapy is a treatment that aims to prevent recurrence of breast tumors that express hormone receptors. Approximately 60% of breast cancers have estrogen and progesterone receptors. These tumors live and grow under the stimulation of the patient’s hormones.
When these patients are diagnosed at an early stage and the tumor is removed, there is still a risk that the tumor has released cells throughout the body that are settled in the bone, in lymph nodes or in other organs and those cells, if nothing is done, can reproduce the disease at a distance within 2, 3 or 4 years.
And that is why adjuvant endocrine treatments are used, which aim to destroy these cells. These are oral treatments with pills that must be taken for several years. All patients who have positive hormone receptors are given hormone therapy, and it has been shown that this greatly reduces the rate of relapses.
How does a patient know if she is a candidate to receive this therapy?
Through the immunohistochemical study of your tumor. The pathologist performs an immunohistochemical study of the tumor and if it stains for estrogen receptors such as closterone, it means that the tumor depends on the woman’s estrogens to grow. And if we give an endocrine hormonal treatment that is antiestrogenic, we cause those cells to die, so that they cannot survive if they exist. Not all patients would need it, but since they are low-toxic treatments, we give them to practically all women with the disease.
Is the treatment 100% effective?
In medicine, nothing is 100% effective. I’m sorry, but that doesn’t exist and anyone who says otherwise is lying. Every treatment reduces the risk, but it can never be said that it completely abolishes it. There are various endocrine treatments, some less effective, others more effective. There are those that reduce the risk more or less and it also depends on the patient’s risk of relapse. That is, if a patient has a 50% risk of relapse, it is logical to expect that risk to be reduced with hormones, with endocrine treatment by 10% or 15%, no more.
We can never ever guarantee that there is a 100% risk reduction, but we can guarantee that as a statistical group, if you treat 1,000 patients with sensitive endocrine tumors, a significant percentage who were going to relapse if you did nothing, with endocrine therapy they do not relapse. Now, the difficult thing to know is which will be the patient you cure and which will be the one who relapses despite everything. We cannot know that today.
And when they relapse, is there another treatment?
Relapses of hormone-sensitive breast cancer are not curable today. So the goal of treatment now is to prolong survival as much as possible, while maintaining a good quality of life. When I started treating breast cancer, many years ago, these women lived an average of a year and a half. Now they live an average of more than 5 years, which may not seem like much, but for these patients it is a lot.
A median, to be more correct, of more than 5 years means that 50% live more than 5 years and in very good conditions, leading a normal life. Because breast cancer is a disease that, although it has metastases, if treated well, does not have to cause symptoms. It is not like esophageal or pancreatic cancer in which the patient is malnourished, loses weight, has no appetite, is bedridden. Breast cancer is compatible with a perfect quality of life until very advanced stages of the disease, when it can no longer be controlled. And therefore, it is worth it.
What is the goal with these patients if they can never be cured?
Prolong survival so much that we can make the disease chronic. That is to say, even if they always have to be treated, if we manage to get them to live a median of 20 years, then we can probably be satisfied because that is what they were going to live without the disease. It happens the same as with diabetes. With diabetes, when there was no insulin or medication, patients died. Now we don’t cure them, but we make them live the same life as if they didn’t have diabetes.
What would be the side effects of this therapy?
Hormonal therapy can cause some type of disorder such as hot flashes and joint pain that is usually morning, as well as joint stiffness. It usually improves over time and they improve a lot with physical exercise. It also depends on the type of endocrine medication because there are several, but in general it is considered that the effects are acceptable because many patients are on them for 5, 7 or 10 years. If it weren’t like that, they wouldn’t be with them for so long.
We are also always trying to find ways to minimize the side effects of endocrine therapy. It may seem like a paradox, but regular physical exercise is what helps these patients the most. In my hospital in Madrid, which is new, we have created a gym for patients so that they can do regular physical exercise. Because this is essential. It is increasingly clear that physical exercise helps women with breast cancer a great deal.
How do you see the panorama of breast cancer today?
Progressively improving. There are differences between countries. The difference between countries that have population screening campaigns and those that do not is key. Population screening consists of the government summoning all women from a certain age, through the lists it has of those registered in a country. When they are 50 years old or older in Spain or 45 years old in some region, they are called to do a control mammogram. Without them having any symptoms, that is screening. If they have symptoms, it is no longer screening, it is already a diagnosis. In Spain, approximately 75% of women participate in these campaigns, which is considered a sufficiently useful complement. And with this, small tumors are detected that are very curable. And they are also cured with less aggressiveness than if you let it develop and diagnose when there is a mass. So, countries that have screening campaigns have a better prognosis for patients and are cured much more than those that do not have them.
Young women no longer have children and this apparently leads to an increase in breast cancer rates. Why?
That’s completely correct. Not so much as not having children, because some women don’t want to, but they do want to have them at 40, 39 or as late as possible so that it doesn’t affect their professional career. This is understandable. The problem is that having children early, having several, and breastfeeding reduces the risk of breast cancer. My mother had six children, but the next generations have two or one or none. So, the number of children influences the risk and especially the timing of the first pregnancy. The earlier it is, the more protective against breast cancer it is. In Spain, right now, I think the median age of the first child is 37 or 38 years old, when before it was 21.
What other factors affect breast cancer?
Well, we are eating very badly, we eat processed food and we have unacceptable diets. Studies by the Spanish Breast Cancer Research Group have shown that a Mediterranean diet reduces the risk of this cancer. The Mediterranean diet is legumes, vegetables, fruit, nuts, cereals with fibre, fish, trying not to eat red meat or reducing it. You should not drink alcohol if possible, which is also a negative factor and, above all, do not eat processed foods. Processed foods have all kinds of carcinogenic additives and we do not know about it.
Another thing that is very important is to avoid obesity, and there is more and more obesity, because now people are sitting looking at their cell phones instead of walking, instead of exercising, and obesity is also an important risk factor for breast cancer.
What do you think about these meetings in which doctors from various countries share research and knowledge about cancer in Spanish?
I think the idea of this symposium is to bring together doctors who have a similar idea, which may seem like nonsense. Because it seems that science is universal and has nothing to do with language, but this is not the case. Current medicine is team medicine, it is not individualized medicine, there are no longer geniuses who are capable of discovering something on their own, now it is a team effort and teams between people who have cultural and linguistic affinities are much easier to carry. In Latin medicine there is a lot of talent in doctors and researchers. Maybe a little organization is missing. So we are trying to get together and find ways to collaborate, to organize and to carry out studies and improve the results of the treatments available for women with breast cancer.