Bénéfices sur la survie de l’activité physique avant ou après un cancer du sein

L’activité physique (AP) s’intègre dans les soins de support en améliorant les possibilités fonctionnelles de l’organisme et la qualité de vie des patientes. Il s’agit du seul facteur modifiant de fa?on établie la fatigue des patients cancéreux. L’AP modifie la survie en diminuant le taux de rechute des cancers du sein et l’impact des comorbidités. Les mécanismes d’action de l’exercice physique sur la maladie cancéreuse sont décrits.     

Cancer du sein triple-négatif : caractéristiques histocliniques et moléculaires,prise en charge et perspectives thérapeutiques

Triple-negative breast cancer (TNBC), as defined by the absence of estrogen and progesterone receptor expression, as well as the lack of HER2 overexpression/amplification, corresponds to 15% of breast cancer and represents an aggressive form of the disease. TNBC are frequently confounded with basal subtype in the molecular classification of breast cancer and also share some similarities with BRCA1-mutated tumors. Epidemiological and clinical characteristics are distinct from other subtypes, including a younger age at diagnosis, a higher risk of relapse in spite of increased chemosensitivity, and a higher incidence of lung and brain metastatic relapses. Conventional cytotoxics remain the mainstay of current systemic management but recent evaluation of more targeted therapeutics, including specific cytotoxics (such as the use of platinum salts), PARP and EGFR inhibition, and antiangiogenics have been performed, providing contrasted but rather disappointing results. Recent data indicate that TNBC represent a heterogeneous entity composed of multiple and distinct molecular subtypes, which should deserve specific targeted therapeutics.     

Perception de l’activité physique adaptée par les parents d’enfants hospitalisés en oncologie-hématologie pédiatrique

The role of adapted physical activity (APA) in adult oncology is becoming increasingly important due to its effect on fatigue and quality of life, but also on patient survival. In contrast, there is very little data concerning children. Our study reports the results of the perception of parents regarding adapted physical activity implemented in a paediatric onco-haematology department for children sometimes in sterile rooms. Although the effect is low (N = 13), it would appear that the timing of the sessions (particularly for young children) and the initial state of tiredness of the children are significant factors for parents. With regards to parent satisfaction, overall they appear to be satisfied without any correlation between satisfaction and the number of sessions being observed. Notions of independence, potential, pleasure in relationships and relaxation appear in the positive evaluation. This activity seems to enable parents to change their perceptions about their child and their relationship to him/her. These initial results suggest the implementation of a wider study.     

Toxicité rectale de la radiothérapie : signes cliniques,physiopathologie et prise en charge

Radiotherapy is a major treatment of pelvic tumours. It exposes to the risk of acute and long-term side effects, such as radiation proctitis. Radiation proctitis is a complex disease requiring support ranging from initial contact with the patient until several years after completion of radiotherapy. This care includes preventive measures (clinical and dosimetric factors), detection and medical and surgical treatments. This article aims to make a review of radiation proctitis induced during the treatment of pelvic cancers.     

Radiothérapie et thérapie ciblée pour la prise en charge du cancer du sein : mise au point

The purpose of this study was to review the current knowledge regarding combinations of the most commonly used targeted therapies or those under development for the management of breast cancer with radiation therapy. Several studies have shown that the combination of radiation therapy and tamoxifen increased the risk of radiation-induced lung toxicity; therefore, the two modalities are generally not given concurrently. The combination of HER2 inhibitors (trastuzumab, pertuzumab) and radiation therapy appeared to be safe. However, trastuzumab emtansine (T-DM1) should not be given concomitantly with brain radiation therapy because this combination may increase the risk of brain radionecrosis. The combination of radiation therapy with other new targeted therapies such as new selective estrogen receptor modulators (SERDs), lapatinib, cell cycle inhibitors, immune checkpoint inhibitors, or molecules acting on DNA damage repair seems feasible but has been mainly evaluated on retrospective or prospective studies with small numbers of patients. Moreover, there is a great heterogeneity between these studies regarding the dose and fractionation used in radiotherapy, the dosage of systemic treatments and the sequence of treatments used. Therefore, the combination of these new molecules with radiotherapy should be proposed sparingly, under close monitoring, pending the ongoing prospective studies cited in this review.     

Étude QUALIOR : faisabilité et efficacité d’un programme d’activité physique adaptée standardisée et encadrée à domicile chez des patients bénéficiant d’une thérapie ciblée orale pour un cancer métastatique

The adverse effect most commonly reported by patients treated with oral targeted therapies for advanced cancer is the onset of fatigue, which may be a limiting factor in long-term tolerance of these treatments. Adapted physical activity (APA) has a demonstrated its beneficial effect on the level of fatigue experienced by patients treated for localised cancer and, under certain circumstances, has shown an improvement in survival. The majority of studies were conducted in the post-cancer period or during the treatment phase, with chemotherapy and/or radiotherapy. Very few studies have been carried out on patients treated with oral targeted therapies. APA programmes vary in quality in terms of their objectives and the ways in which they are carried out and assessed. Particularly for patients with fatigue who have an advanced illness, it is important to assess supervised, home-based APA programmes. The QUALIOR study, sponsored by Unicancer, is a phase II–III randomised study, with the aim of thoroughly assessing the implementation of a 3-month home-based APA programme for more than 300 patients treated with targeted therapy for an advanced cancer (including breast, kidney and lung cancer plus a diverse cohort) in improving fatigue and quality of life, as well as full-term treatment compliance. A secondary objective is to evaluate progression-free survival. This programme is also assessed for its medico-economic relevance. The feasibility of the APA programme, which has been designed with various intensity levels, is assessed during the phase II study, which will then be continued with a phase III study to measure the programme’s efficacy. The final objective is to provide access to supervised APA sessions, specifically aimed at patients treated with these new targeted therapies, within the framework of a supportive care activity.     

Réentraînement à l’activité physique dans la prise en charge globale du cancer du sein : étude pilote monocentrique

ObjectivesThe objective of the present study is to report the pilot experience at the « Loire cardiorespiratory readaptation center » of re-entrainment of physical activity for patients suffering from breast cancer.Patients and methodsBetween January 2012 and February 2013, 63 patients took the program at the readaptation center. The program is composed of three sessions a week during seven weeks. During the care, a medical team intervenes. It is composed of a cardiologist, a physiotherapist, a sophrologist, a psychologist and a dietician who take part in turns and/or together.ResultsDuring the first session of the program, the warm-up power chosen on the exercise bike was on average of 14.72 watts (min = 5; max = 30), and it went up to 44.84 watts (min = 15; max = 85) on average during the last session. The maximal power used by the patient was on average of 39.08 watts (min = 10; max = 70) during the first session. On the last day of training, the average maximal power between the patients was of 76.03 watts (min = 30; max = 110).ConclusionThe tests used into practice tend to confirm a physical progression between the beginning and the end of the re-training program. This study particularly shows that it is possible today to propose this type of program to the patients in daily practice.     

Comprendre la non-adhésion à l’activité physique après un diagnostic de cancer pour mieux accompagner les patients—Partie I : Comprendre la non-adhésion à une pratique régulière d’activité physique

This article presents a conceptual framework at the physiological-and-psychological dimensions interface (3H Syndrome or sedentary process) to understand the process of non-involvement and why some cancer patients remain away from regular physical activity or physical activity programs. In this first part, we have shown how the dynamics of the interactions between the individual’s available physical resources and the relationship that the person keeps with physical activity can bring insight into this process.     

Méningiomes de la base du crâne : efficacité et tolérance clinique,efficacité radiologique et cinétique tumorale après radiothérapie

Skull base meningioma leads to functional disturbances, which can significantly alter the quality of life. The optimal management of these lesions, whose goals are neurological preservation and tumour local control, is not yet clearly established. It is widely recognized that the goal of a radical excision should be abandoned despite the advances in the field of microsurgery of skull base lesions. Although less morbid, partial tumour excision would be associated with increased risk of local tumour recurrence. Although discussed both exclusive and adjuvant have proven to be highly successful in terms of clinical improvement and local control. Various radiation techniques have demonstrated their efficacy in the management of this pathology. However, high rates of clinical improvement are in contrast with low rates of radiological improvement. The notion of clinical and radiological dissociation appeared. However, in most of these studies, the analysis of the radiological response could be subject of legitimate criticism. This work proposes to review the local control, the efficacy and the clinical tolerance and the radiological response of the various radiation techniques for the meningioma of the base of the skull and to demonstrate the interest of quantitative volumetric analyses in the follow-up of meningioma after radiotherapy.     

Thérapeutiques ciblées dans les tumeurs de l’os et des tissus mous : vers une prise en charge individualisée

Sarcomas are rare types of tumours which present wide variations in their clinical and biological characteristics. In spite of successful locoregional treatment, metastasis will occur in close to 40% of patients. As a rule, doxorubicin is the first-line therapy for patients who have a metastatic soft tissue sarcoma, with very modest results. However, targeting the molecular anomalies which are characteristic of sarcomas could lead to improved patient survival, as has been demonstrated for gastrointestinal stroma tumours and dermatofibrosarcomas. Several clinical trials to evaluate new agents such as cell cycle inhibitors or anti-angiogenic drugs are currently under way. Molecules targeting the epigenetic anomalies of sarcomas are also a promising form of treatment. Finally, the use of nanotechnologies is creating new, original therapies currently under clinical evaluation, particularly in association with radiotherapy.     

Utilité d’une prise en charge psychologique et sociale dans les problématiques de retour à l’emploi après un cancer

Getting back to work after a cancer is a major milestone in the patient’s course. Restoring a normal professional life is key to rehabilitation but might be a tough period to go through. The psychological and social consultations of Accueil Cancer de la Ville de Paris take care of the troubles related to professional life restart. A social worker referring patients to a psychologist is usual when professional life restoration is at stake, emphasizing how post-cancer psychological issues are difficult to manage. The aim of this clinical article is to underline: 1) how the social worker/psychologist partnership enlightens on professional life restoration matters after a cancer; 2) how psychic issues bring problems as far as reintegration into professional life is concerned.     

Toxicité œsophagienne de la radiothérapie : clinique,facteurs de risque et prise en charge

Acute radiation-induced esophagitis includes all clinical symptoms (odynophagia, dysphagia) occurring within 90 days after thoracic irradiation start. Its severity can be graded using RTOG and CTCAE scales. The clinical risk factors are: age, female gender, initial performance status, pre-therapeutic body mass index, pre-therapeutic dysphagia, tumoral and nodal stage, delivered dose, accelerated hyperfractionned radiotherapy, concomitant association of chemotherapy to radiotherapy and response to the treatment. The dosimetric parameters predictive of esophagitis are: mean dose, V_20Gy, V_30Gy, V_40Gy, V_45Gy and V_50Gy. Amifostine is the only drug to have a proven radioprotective efficacy (evidence level C, ESMO recommendation grade III). The medical management of esophagitis associates a diet excluding irritant food, medication against gastroesophageal reflux, analgesic treatment according to the WHO scale and management of dehydration and denutrition by enteral feeding.     

Carcinomes épidermoïdes de l’hypopharynx et du larynx : prise en charge fondée sur les preuves

Squamous cell carcinomas of larynx and hypopharynx can be treated by surgery and/or radiotherapy according to tumor size. For small tumors, the results are similar. For locally advanced tumors, the surgical approach is mutilating and requires a total (pharyngo)laryngectomy. Exclusive chemoradiotherapy has shorow>n its interest at the cost of late sequelae. In order to reduce these effects and mutilation, induction chemotherapy row>ith cisplatin, docetaxel and 5FU for organ preservation becomes the standard treatment but there are no solid studies comparing this approach row>ith the exclusive chemoradiotherapy. And it is not possible to conclude as to the superiority of a scheme in terms of overall survival. ROW>hen chemotherapy is chosen, the modalities of any potentiation of radiation have not been yet established.     

Immunothérapie et radiothérapie dans la prise en charge du cancer du sein : rationnel et synthèse de la littérature sur les applications cliniques actuelles

The discovery of immunotherapy led to understand the major role of immune system during the tumor process. Conventional treatments, such as chemotherapy, are directly tumoricidal. New drugs are developed to target specifically the immune system to make it regain its ability to recognize and eliminate cancer cells. Radiotherapy is used for a long time for its local action, but its systemic role, based on its impact on immunity, is now better known. Breast cancer was wrongly considered poorly immunogenic and put aside the amazing progress in this new area of treatment. In this article, we would like to present the pre-clinical and clinical rationales to associate immunotherapy to radiotherapy in the management of breast cancer.     

uPA/PAI-1, Oncotype DX™, MammaPrint® Valeurs pronostique et prédictive pour une utilité clinique dans la prise en charge du cancer du sein

Context and Aims

Breast cancer prognosis and predictive biomarkers development would allow sparing some patients from chemotherapy or identifying patients for whom chemotherapy would be indicated. In this context, in 2009, the French National Cancer Institute, a National Health and Science Agency dedicated to cancer, in collaboration with the « Société française de sénologie et de pathologie mammaire » published a report on the assessment of the prognostic and the predictive clinical validity of tissular biomarkers, uPA/PAI-1, Oncotype DX? and MammaPrint ®, in breast cancer management. They concluded that only the uPA/PAI-1 prognosis value reached the highest level of evidence (LOE I according to Hayes 1998 classification). In 2012, it was decided to update this report since new data have emerged and because information disparities among clinicians have been identified. This article aims to present the main conclusions together with the levels of evidence associated with those conclusions.

Methods

The updating process was based on literature published since 2009 appraisal and on multidisciplinary and independent experts’ opinion. The levels of evidence (LOE) used are those of the classification defined by Simon in 2009 (updated Hayes 1998 classification): LOE IA and LOE IB: high level of evidence; LOE IIB and LOE IIC: intermediate level of evidence; LOE IIIC and LOE IV-VD: low level of evidence.

Conclusions

Among patients without lymph-node involvement, uPA/PAI-1, invasion process biomarkers, reach the highest level of evidence for 10 years recurrence free survival prognosis (LOE IA according to Simon). The predictive value to anthracyclins chemotherapy remains to be confirmed. No data were identified on uPA/PAI-1 medico-economic value. Oncotype DX? and MammaPrint® prognosis and predictive value do not reach the LOE I level. This updating’ process confirms the 2009 levels of evidence for all the three biomarkers prognosis value. Besides, concerning Oncotype DX? and MammaPrint®, new data do not allow to conclude neither to their complementary clinical information to other clinicopathological existing biomarkers nor to a favorable cost-efficiency ratio in therapeutic decision making and this because of the methodological weakness and uncertainty that are identified in the selected studies. Practically, beyond the prognosis and predictive biomarkers validity, the clinical utility of a new biomarker for chemotherapy indication depends on its clinical added information with regard to validated biomarkers (HR, HER2 and Ki67) and to clinicopathological parameters. Since they are the sole validated biomarkers of the invasion process, uPA/PAI-1 could complete clinical information of other clinicopathological factors and consequently could confer an added clinical value. However, data concerning the impact of this information on chemotherapy clinical indication are lacking.     

Métastases cérébrales multiples d’un cancer du sein et leur prise en charge en radiothérapie : quelle est l’attitude thérapeutique la mieux adaptée ?

Whole brain radiotherapy remains standard in the management of breast cancer patients with brain metastases. It allows for symptomatic improvement and good local control in most patients. However, its results remain suboptimal in terms of both efficacy and toxicity. In highly selected patients, stereotactic radiotherapy demonstrated very good local control with low toxicity. With purpose of improving the efficacy/toxicity ratio, strategies of biomodulation of tumor radiosensitivity were recently developed. First results are promising and warrant further assessment. At the same time, new technologies and new irradiation modalities demonstrated their ability in providing high dosimetric homogeneity, delivering integrated radiation boosts, and avoiding critical structures that are involved in long-term neurological toxicity. Further assessment is required and recruitment of breast cancer patients into clinical trials is encouraged.