Preservación de la fertilidad: opinión de grupo de expertos en México / Fertility preservation: an expert taskforce opinion

La preservación de la fertilidad es la aplicación de estrategias médicas y de laboratorio para preservar la descendencia genética parental en adultos o niños en riesgo de esterilidad. El cáncer es la principal indicación de preservación de fertilidad en pacientes en edad reproductiva. En las últimas décadas ha incrementado la incidencia de cáncer en adolescentes. Los tratamientos oncológicos también han mejorado significativamente, por lo que hoy es posible la curación en un amplio porcentaje de pacientes. La mayoría de los niños y adolescentes con cáncer se convierten en sobrevivientes a largo plazo, lo que aumenta el interés en los efectos del tratamiento del cáncer sobre la fertilidad. Las condiciones sociales, económicas y culturales también son determinantes para decidir el momento que una pareja busque promover su fertilidad. Además, otras patologías o incluso fármacos para prevención del rechazo de órganos trasplantados pueden afectar la fertilidad y, por tanto, tales pacientes son susceptibles de orientación sobre preservación de la fertilidad. El éxito en los programas de reproducción asistida y en los tratamientos oncológicos brindan alternativas para preservar la fertilidad. En esta primera Opinión de Grupo de Expertos Mexicanos en Preservación de la Fertilidad hemos evaluado pacientes oncológicas que son candidatas a preservación de fertilidad: jóvenes con riesgo de compromiso de su fertilidad por el tratamiento oncológico, pero con reserva ovárica suficiente y pronóstico vital aceptable. También se consideraron casos especiales como la preservación social, en casos de conceptualización sexual diferente, así como los aspectos legales y éticos básicos

Fertility preservation is the application of medical and laboratory strategies to preserve parental genetic offspring in adults or children at risk of sterility. Cancer is the main indication of fertility preservation in patients of reproductive age. In recent decades, the incidence of cancer in adolescents has increased. Cancer treatments have also improved significantly, making cure possible today in a large percentage of patients. Most children and adolescents with cancer become long-term survivors, increasing interest in the effects of cancer treatment on fertility. Social, economic and cultural conditions are also decisive in deciding when a couple seeks to promote their fertility. Furthermore, other pathologies or even drugs for the prevention of rejection of transplanted organs can affect fertility and, therefore, such patients are susceptible to guidance on fertility preservation. Success in assisted reproduction programs and cancer treatments provide alternatives to preserve fertility. In this first Opinion of the Group of Mexican Experts on Fertility Preservation, we have evaluated oncological patients who are candidates for fertility preservation: young people at risk of compromising their fertility due to oncological treatment, but with sufficient ovarian reserve and acceptable vital prognosis. Special cases such as social preservation were also considered, in cases of different sexual conceptualization, as well as the basic legal and ethical aspects

An Uncommon Case of Bilateral Breast Enlargement Diagnosed as Tumoral Pseudoangiomatous Stromal Hyperplasia: Imaging and Pathological Findings.

The incidence of reported pseudoangiomatous stromal hyperplasia (PASH), as well as the variability and severity of clinical presentations, is increasing in the literature. In parallel, several authors posit the need for an improved classification of PASH to avoid possible variables associated with this diagnosis. Here, we present a 25-year-old woman with PASH accompanied by severe bilateral and symmetrical breasts enlargement, highlighting an uncommon clinical presentation of PASH as much as the careful interdisciplinary review and correlation of histology and all available imaging studies to confirm the definitive diagnosis.

Cost-effectiveness of the 21-gene breast cancer assay in Mexico.

INTRODUCTION: The 21-gene breast cancer assay (Oncotype DX(®); Genomic Health, Inc.) is a validated diagnostic test that predicts the likelihood of adjuvant chemotherapy benefit and 10-year risk of distant recurrence in patients with hormone-receptor-positive, human epidermal growth receptor 2-negative, early-stage breast cancer. The aim of this analysis was to evaluate the cost-effectiveness of using the assay to inform adjuvant chemotherapy decisions in Mexico. METHODS: A Markov model was developed to make long-term projections of distant recurrence, survival, and direct costs in scenarios using conventional diagnostic procedures or the 21-gene assay to inform adjuvant chemotherapy recommendations. Transition probabilities and risk adjustment were taken from published landmark trials. Costs [2011 Mexican Pesos (MXN)] were estimated from an Instituto Mexicano del Seguro Social perspective. Costs and clinical benefits were discounted at 5% annually. RESULTS: Following assay testing, approximately 66% of patients previously receiving chemotherapy were recommended to receive hormone therapy only after consideration of assay results. Furthermore, approximately 10% of those previously allocated hormone therapy alone had their recommendation changed to add chemotherapy. This optimized therapy allocation led to improved mean life expectancy by 0.068 years per patient and increased direct costs by MXN 1707 [2011 United States Dollars (USD) 129] per patient versus usual care. This is equated to an incremental cost-effectiveness ratio (ICER) of MXN 25,244 (USD 1914) per life-year gained. CONCLUSION: In early-stage breast cancer patients in Mexico, guiding decision making on adjuvant therapy using the 21-gene assay was projected to improve life expectancy in comparison with the current standard of care, with an ICER of MXN 25,244 (USD 1914) per life-year gained, which is within the range generally considered cost-effective.

A study of the impact of the 21-gene breast cancer assay on the use of adjuvant chemotherapy in women with breast cancer in a Mexican public hospital.

BACKGROUND: The majority of breast cancer patients in Mexico are treated through the public health system and >80% receive adjuvant chemotherapy. The aim of this prospective study was to characterize the impact of the Oncotype DX assay on adjuvant therapy decision making and the confidence in those decisions amongst public sector physicians in Mexico. METHODS: Ninety-eight consecutive patients with ER+, HER2-, stage I-IIIa, N0/N1-3 node-positive breast cancer from the Instituto Nacional de Cancerología were eligible for the study. The primary endpoint was the overall change in treatment recommendations after receiving the assay results. RESULTS: Of 96 patients, 48% received a chemohormonal therapy recommendation prior to testing. Following receipt of results, treatment decisions changed for 31/96 (32%) patients, including 17/62 (27%) node-negative patients and 14/34 (41%) node-positive patients. The proportion of patients with a chemotherapy-based recommendation decreased from 48% pre- to 34% post-assay (P=0.024). 92% of physicians agreed that they were more confident in their treatment recommendation after ordering the assay. CONCLUSIONS: These results suggest that use of the 21-gene assay in the Mexican public health system has a meaningful impact on adjuvant treatment recommendations that may reduce the overall use of chemotherapy.

Impact of diabetes and hyperglycemia on survival in advanced breast cancer patients.

PURPOSE: We examined the impact of diabetes and hyperglycemia on cancer-specific survival of patients with metastatic or recurrent breast cancer (BC). METHODS: We performed a retrospective analysis of 265 patients with advanced BC receiving palliative chemotherapy. BC-specific mortality was compared for diabetic and nondiabetic patients as well as for patients that presented hyperglycemia during treatment. RESULTS: No difference was observed between the diabetic and nondiabetic patients in terms of overall survival (OS). A difference in OS was observed between nondiabetic patients and diabetic patients who had hyperglycemia. The OS was greater in diabetic patients with proper metabolic control than diabetic patients with hyperglycemia. The risk of death was higher in patients with mean glucose levels >130 mg/dL during treatment. Several factors were associated with poor OS: tumor stage, hormone-receptor-negative tumors, HER2 negative disease, multiple metastatic sites, presence of visceral metastases, and mean glucose >130 mg/dL. CONCLUSION: Elevated glucose levels are associated with a poor outcome in diabetic and nondiabetic patients in contrast to patients with normoglycemic levels, conferring an elevated risk of death. According to these results, clinicians should monitor glucose levels during treatment for advanced breast cancer disease and take action to maintain normal glucose levels.