Should triple-negative breast cancer (TNBC) subtype affect local-regional therapy decision making?

The more aggressive biologic characteristics and the current lack of targeted therapy for triple-negative breast cancer (TNBC) make local-regional management decisions challenging for physicians. TNBC is associated with patients of younger age, black race and BRCA1 mutation carriers. Distinctions between BRCA1-associated and sporadic TNBC include increased lifetime risk of ipsilateral and contralateral breast cancer after breast cancer therapy (BCT) for BRCA carriers, which is not shared by sporadic TNBC. However, the presence of a BRCA mutation should not preclude a breast-conservation approach in patients who are otherwise appropriate candidates for BCT. Data suggest that local-regional relapse (LRR) at baseline after BCT appears to be comparable for TNBC and the HER2-positive subgroups, but is about 50% greater than luminal tumors. LRR appears to be similarly increased after mastectomy; thus, TNBC should not be a contra-indication for BCT. Recent hypothesis-generating data suggest less LRR after BCT (where radiation is routinely delivered) than with mastectomy for early-stage TNBC. To date, no specific local-regional guideline recommendations for TNBC exist. Level I outcome data for TNBC using accelerated partial breast irradiation (APBI) and hypofractionated whole-breast irradiation (hWBRT) are lacking. TNBC should be treated with APBI only on clinical trials. Although hWBRT may be considered in TNBC, its association with younger age, advanced disease and use of systemic chemotherapy often precludes its use for this subtype. Until definitive treatment strategies are validated in large datasets and confirmed in randomized trials, TNBC subtype, in and of itself, should not direct local-regional management treatment decisions.

Accelerated partial breast irradiation

Local therapies to treat newly diagnosed breast cancer include a lumpectomy with radiation therapy or a mastectomy. The 20-year data from studies about the safety and efficacy of lumpectomy with full-breast radiation therapy support the safety of this regimen and its role to decrease the risk of ipsilateral recurrence and increase long-term survivorship of women with breast cancer. Accelerated partial breast irradiation (APBI) provides radiation therapy to the tumor bed but spares the remaining breast tissue. APBI accelerates the time required to complete the therapy regimen, with a range of one intraoperative session to five consecutive days compared to five to seven weeks. Several techniques exist to administer APBI, including the insertion of a balloon into the lumpectomy space. Of interest is the widespread use of APBI in community and academic settings that has preceded outcomes of large, randomized clinical trials. Because of selection bias in a number of small, single-institution, nonrandomized studies, published data are of limited value to ensure APBI as a standard of care.

Chemotherapy: still an essential player in non-small-cell lung cancer treatment?

SUMMARY Substantial advances have been made in understanding critical molecular and cellular mechanisms driving tumor initiation; these findings have led to the discovery of a variety of novel drug targets and the development of new treatment strategies. The treatment of non-small-cell lung cancer patients harboring gain-of-function hotspot mutations in EGFR gene or an ALK gene rearrangement, has provided an impressive clinical benefit and changed the management of this disease. The standard of care with cytotoxic chemotherapy empirically based on a patient’s clinicopathologic features is no longer acceptable. Nevertheless, chemotherapy still bears a crucial role in all subsets of patients diagnosed with non-small-cell lung cancer. This article aims to describe the emergence of these new treatment strategies and update the role of chemotherapy in the current setting.