Breast cancer, cutting-edge treatments championing women

The taboo on metastatic breast cancer is falling. "The term 'metastable' is being used a lot to indicate a disease that is controlled over time instead of 'metastatic', which had an extremely negative characterisation". This was said by Professor Paolo Marchetti, president of the Foundation for Personalised Medicine, during the second Sole 24 Ore video forum dedicated to breast cancer prevention month in which new treatments and available therapeutic paths were discussed. Professor Giuseppe Curigliano, Director of New Drug Development for Innovative Therapies at the Ieo (European Institute of Oncology) and President of Esmo for the two-year period 2027-2028, and Professor Rossana Berardi, Professor of Oncology at the Polytechnic University of Marche, Director of the Oncology Clinic at the University Hospital of Marche, were also present.

On the therapies, innovation is galloping, while the implementation of the pathways designed most recently by the National Cancer Plan 2023-2027 is still in progress. "We must emphasise,' Marchetti continues, 'that in our country, but also in many centres, a diagnostic, therapeutic, and assistance pathway dedicated to patients in the metastatic phase of the disease still does not exist, and that very often the decision is taken solely by the oncologist. Instead, it is crucial to arrive at a holistic integration, which 'means taking into account in our patients even modest side effects, which used to be tolerated because the therapies unfortunately had an efficacy of a few months. That is why we have the so-called Proms (Patient-Reported Outcome Measures), i.e. the side effects that are not classified by the oncologist but reported by the patient: we need to integrate knowledge about physical activity, diet, nutritional status, and emotional support of our patients in the more advanced stages of the disease. Because all these factors bring benefits in terms of extra months of life. Let us remember that an organised pathway in metastatic disease only results in a six to eight month survival advantage through an integrated pathway'.

Galleria Borghese

From therapeutic pathways to clinical innovations. The future? "Surely it will be in the progressive substitution of conjugated antibodies to chemotherapy and they will also be combined with immunotherapy," explains Professor Curigliano. "And let's not forget that another category of drugs that has changed clinical practice is immunotherapy, in particular pembrolizumab, which in the preoperative setting has not only increased the percentage of complete response in triple-negative tumours, but has improved survival in the early setting. "I think the most disruptive drug category is definitely conjugated antibodies. After years of studies, especially in metastatic disease, where a survival benefit could not be demonstrated, these drug classes have clearly and unequivocally succeeded in impacting the response rate, the control of time to progression and the survival of these metastatic patients."

Curigliano mentions two classes of conjugated antibodies in particular. "The first category is anti-Trop2 conjugated antibodies, the second is anti-Her2 conjugated antibodies. Certainly the most significant of these is trastuzumab deruxtecan, which resulted in an increase in progression-free survival of 28.8 months. A substantial advantage that has had a historic impact. I can anticipate,' Curigliano announces, 'that this will be the first line of treatment: these drugs have changed clinical practice, but we will see a lot more in the future, because there are at least 300 conjugated antibodies in the trial phase, some of which are also in breast cancer'.

The challenge is also to bring the most appropriate innovation to each patient. "Two are the key words," warns Professor Berardi, "coordination between the various specialists in the choice of treatment options within the patient's pathway, and timeliness, because the rapidity of a precise diagnosis, of access to treatment, and in customising treatment also through the analysis of the woman's biomolecular profile undoubtedly represents a valuable pathway. Moreover, it is essential to monitor it, the pathway implemented with the Breast Units, also through an audit activity that certifies it and verifies the existence of areas for improvement. Another aspect,' he continues, 'is related to interaction with the territory, which has become an important element, especially for women who take oral therapy for a long time and therefore need less medicalisation. Or who are perhaps cared for in a high-intensity hospital but could be partly managed within a coordinated pathway also in facilities closer to home. We can imagine a more widespread and delocalised care for some specific services. I am thinking, for example, of the follow up, or the monitoring of the patient after the initial surgical or therapeutic course, are undoubtedly aspects that could give additional value to an excellent Breast Unit'.