Hospital da Mulher – Caism is offering pioneering assistance to a private group of women in the Metropolitan Region of Campinas (RMC). They are healthy but may have a high genetic risk for gynecological and breast cancer. These women are being treated preventively at the High Risk Outpatient Clinic for Breast and Ovarian Cancer, which is investigating a probable genetic mutation for these diseases.
According to César Cabello dos Santos, professor at the Department of Tocogynecology at the Faculty of Medical Sciences and coordinator of the Mastology Area of the Oncology Division, this is a differentiated service, as the hospital only receives cases of greater complexity, at a tertiary level. “In this situation, however, we are also working in primary and secondary care, due to the great risk to women’s lives, including those who are apparently well.”
According to him, these women come to the clinic with a family history of first-degree breast cancer, pre-menopausal, that is, mothers, sisters or daughters with a history of these cancers before the age of 50. “Around 40% of new breast cancer cases treated by Caism occur below this age, a typical phenomenon in a developing country like Brazil.”
If the mother had breast cancer at a young age, the daughter can now be admitted to this outpatient clinic, where even more serious situations are treated: the grandmother with breast cancer at 45, the mother at 40 and the sister at 30. These combinations have increased the risk of these diseases, according to César Cabello.
Therefore, women with a high-risk family history must undergo a thorough approach, which includes, for example, more frequent visits to the breast specialist and gynecologist. They need greater monitoring and guidanceinformation on screening, contraception, hormone replacement. “Many are not mothers and, for this reason, it is necessary to discuss the preservation of their fertility and, when this is the case, evaluate which contraceptive methods are the safest, because not everyone can take pills or take hormones”, explains the doctor. .
If the risk is very high (above 40%), they are advised on risk-reducing bilateral mastectomies, with breast removal; and risk-reducing salpingo-oophorectomies, with removal of the ovaries (oophorectomy) and the fallopian tube (tubal ligation). Those Risk-reducing surgeries are popularly called mastectomies and prophylactic salpingo-oophorectomies.
Medical Exams
Patients who arrive at the outpatient clinic are screened through diagnostic imaging. It turns out that current screening programs are practically restricted to mammography and ultrasound in the Unified Health System (SUS). Breast MRI is indicated when there is a risk of breast cancer above 20%.
“The prevention program that integrates these three tools produces a very positive impact on health”, explains the mastologist. “Although they are not able to reveal cancer in 100% of cases, they reduce the risk of death in 90% of them. And this has generated curiosity in both the scientific community and the population.”
For Cabello, mammography, ultrasound and breast MRI may, however, be insufficient and are only used for a period of time until surgery is chosen. In the case of mastectomies, as they are invasive, at Caism we recommend reconstruction with prostheses suitable for each patient and with the best plastic surgery techniques (oncoplasty).
The professor also highlights that, with the increase in genetic tests, it would actually be possible to select today which women with a family history would benefit from surgery. But these tests are not part of the list of exams allowed by the SUS.
Because of this, Caism is currently seeking resources to make genetic tests a reality in the hospital, as they would help identify those at very high risk for these cancers. Funding is being attempted through research projects, contributions from the third sector, public-private partnerships, etc.
“When we find a gene associated with a high risk in a healthy woman, the correct way to assess this is to study the mother, sister or daughter with the pathology, finding the mutation in them as well. A healthy person, under 50 years of age, who has the mutation has a very high risk and is recommended for surgery”, he highlights.
Rehabilitation
Another stage of care for these women involves rehabilitation, carried out in a multidisciplinary manner (by professionals from nursing, psychology, physiotherapy, doctors and oncoplasty surgeons). A plan is made about what is best for the patient and her quality of life, also counting on her participation in decision-making.
A major challenge for the SUS is to be able to individualize the screening and approach to these women, as there are an estimated 59 new cases of breast cancer in Brazil in 2018, says Cabello. Even though these techniques are not very widespread in the public service, the expectation is that women will no longer die from this cause in CMR, says the mastologist.
According to him, even with some difficulties, the hospital has tried to adapt to the reality of the population. Most women with ovarian cancer in their youth, and with tumors of the epithelial lineage, have a high chance of having genetic alterations and a high risk of breast cancer as well..
The main risk factor for ovarian cancer, he mentions, is family history. “There are women with families who have breast and ovarian cancer, breast and bowel cancer, breast and thyroid cancer, whose interconnections are important and classify those who are really at high risk,” she says.
Outpatient clinic
Cabello comments that this Caism outpatient clinic has an internal demand for patients. “Many immediate relatives of women we investigate for possible breast cancer are summoned. But we also receive women referred through the public network.”
As a result, the hospital faces a serious problem: treatment is expensive and space to treat them is limited. “The limitation is physical and human. We would certainly like to expand our outpatient clinic, however we already face the problem of caring for confirmed cases of cancer”, he explains.
But the doctor believes that, with more resources, it will be possible to expand care. “This is a university service in which we have students, residents, doctors, postgraduate students and other health professionals. Working together with the idea of looking for high-risk cases, we can certainly reduce mortality from the disease.”
On the other hand, awareness of the high risk of cancer, he believes, must be raised among women, patients and those who care for this population. “This concept is fundamental and, within our possibilities, we try to do a good job with this group and we have done school on this subject”, he says.
