Genetic burden and family history sometimes play a key role in the development of breast cancer. This is what the head of the Medical Oncology Clinic at Acibadem City Clinic Tokuda University Hospital, Assoc. Dr. Zhelyazko Arabadzhiev, who is among the organizers of the first conference in Bulgaria, dedicated to the complex treatment of breast carcinoma, licensed by the European Society of Medical Oncology ( ESMO).
- Associate Professor Arabadzhiev, what is the trend – sooner or later breast cancer is detected in our country?
- If we retrospectively analyze the situation with the detectability and diagnosis of breast cancer, then definitely nowadays this type of cancer is detected much earlier than it was 20-30 or 40 years ago. And this is so for many reasons. As the first reason, we can note the increased diagnostic possibilities with the introduction of MRI, computed tomography, mammography with tomosynthesis and the easiest to perform ultrasound examination of the breast. Of course, we are talking here about the accessibility of these imaging methods to all citizens. But what is striking is that there is a part of the population that comes to the doctors, to the oncologists at a more advanced stage of the disease, and that intentionally. Literally days ago I had such a case of self-diagnosis. A woman feels a lump in her breast, which grows over time, but because of some fear, because of an expectation of reverse development, because of some uncertainty, because of distrust in the health system, because of distrust in doctors, she waits… And it happens that the disease progresses so much that it turns out to be almost at the last stage of the disease, when we already have a complete infection of the breast, it already comes to the surface of the skin and so on. In this sense, yes, there is a significant improvement in detectability, but there is still a need to strengthen public trust in Bulgarian medicine and Bulgarian doctors. And here I open a bracket. This is the most important thing - the problem of early detection of breast carcinoma will be largely solved with the introduction and adoption of National Screening of this disease. This is something very important, because the National Program covers a certain group of the population.
- And is there an age at which women are most vulnerable, or are things individual?
- Statistics show that the highest percentage of breast cancer is diagnosed in the 55-60-65 age group.
- Is there an explanation why…
- That's the statistics. In general, oncological diseases are most common and begin to manifest in the fifth and sixth decade of human life. And for many reasons - a combination of environmental risk factors, trauma, various genetic mutations that create the ground for the development of cancer cells over time, as well as numerous external influences. But, unfortunately, as with other oncological diseases, and with breast carcinoma, a rejuvenation of the disease is noticed. We see patients who are in their fourth decade of life – 35-40 years, and even much younger.
- You mentioned screening… If we are talking about prevention, at what age should women be examined?
- Currently, there is a mandatory preventive examination of working citizens, which is once a year. In the screening program, the rules for conducting this purposeful preventive examination, which covers women aged 45 to 74, are more clearly written. And this is the last decision of the European Commission, because it changed the age limit - reduced the lower limit and increased the upper one. As for women aged 50-69, examinations are every 2 years, and from 70-74 – 3 years old. We are talking about people who lack risk factors.
- There is known to be a familial burden in breast cancer. Tell us more about the inherited gene mutations BRCA1 and BRCA2...
- In the case of gene mutations, we are talking about about 10% of women. It is important to know that gene mutations create prerequisites for the development of breast cancer, but it does not necessarily happen. A few days ago I came home from a conference of the American Society of Clinical Oncology in Chicago, where I had the pleasure of personally listening to the lecture by Prof. Jennifer Pietenpohl, who proved the role of the mutation – TP 53 responsible for the development of one type of breast cancer. With gene mutations in 10% of the population, about 13-14% may have BRCA1 and BRCA2, respectively. These mutations have been talked about a lot and became known around Angelina Jolie, who had her body cells tested and found that she had these mutations. After that, she removed both her breasts and both ovaries as a preventive measure, because carriers of this genetic mutation have an increased risk of developing breast carcinoma.
- What percentage of people who have these gene mutations develop breast cancer?
- It is difficult for me to answer exactly, but about 35-40% of patients who have these mutations develop breast cancer over time. So we can take this percentage as valid. The study of these mutations is so important that if they are found, the patient falls into a certain group and is monitored better. If they are found, it is good to research the family – especially for girls, but it's good for boys too, because BRCA1 and BRCA2 in men can be risky for prostate cancer, pancreatic cancer, and so on.
- What is the process of determining the most appropriate treatment for breast cancer and who are the main decision makers?
- This is, perhaps, one of the most important questions that reflects the modern understanding of complex treatment of breast carcinoma - in the world, in the USA, in Europe and already in Bulgaria. The decision to treat breast carcinoma should be made in a multidisciplinary team. There are many synonyms for this - tumor board, oncology commission, oncology committee, etc. All are synonyms pointing to a multidisciplinary discussion. This commission, let's call it, includes a medical oncologist who most often coordinates things and is the chairman, a surgeon, sometimes a molecular biologist or a geneticist, because you see how important the genetic link is, an imaging diagnostician – the one who does mammograms and ultrasounds, magnetic resonance, and the decisions are made in a complex manner. The decision is based on the opinion of each of these members. And another very important thing is that decisions must be made by this team at every stage of the disease - not only at the beginning, not only in the middle, not only at the end, but at every stage. I give an example. A patient who has been diagnosed and is about to have surgery, may need pre-operative chemo or radiation, may undergo hormone therapy… At any progression of the disease, at any change of treatment, in the course of a more advanced disease, the sequence of decisions is key. Each patient is different and should be approached individually.
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Assoc. Dr. Zhelyazko Arabadzhiev is the Chairman of the Board of the Institute for Research on the Treatment of Breast Cancer and of the Bulgarian Scientific Society of Immuno-Oncology. He is a part-time assistant at the "Propaedeutics of Internal Diseases" Department, "Medicine" Faculty. in SU “ St. Kliment Ohridski“. Author and co-author of more than 60 publications in national and international specialized scientific journals, he participated in the publication of manuals, textbooks, monographs and textbooks in the field of cancer treatment. Prof. Arabadzhiev is also a member of editorial boards of international and national refereed and indexed scientific publications. Principal investigator and sub-investigator in international multicenter clinical trials. Member of the Board of the European Commission Cancer Mission.