Prognostic and predictive parameters of breast cancer: The role o f pathologist in the Sri Lankan perspective

Abstract

Breast cancer has been and continues to be a major health problem. The incidence * o f breast cancer has increased globally over the last several decades and the greatest increase has been seen in Asian countries. It has become the com m onest cancer in Sri Lanka irrespective o f the gender. Although breast cancer is a cancer with a good prognosis if detected and treated early, most o f our patients seek medical attention at an advanced stage o f the disease. Most o f them have high grade tumours. Breast cancer comprises an extraordinarily diverse group o f diseases in terms of presentation, morphology, biological characteristics and clinical behaviour. Tumours o f apparently homogenous morphology still vary in response to therapy and have distinct outcomes. Therefore, management o f breast cancer has become a challenging task. The role o f the pathologist has evolved parallel to the improvements in the management. The traditional role o f pathologist was to diagnose breast cancer, but the emerging challenge is to provide the maximum prognostic and predictive information so that the best tailored therapy is given to the patient. Prognostic factors are important for forecasting outcomes in individual patients and can be used to refine treatment choices. Predictive factors are measurements associated with the degree o f response to a specific therapy. At present hormone receptor status is the well defined predictive factor o f breast cancer in predicting the responsiveness to hormonal therapy. The recommended prognostic and predictive factors o f breast cancer include age, tumour size, axillary lymph node status, histological tumour type, pathological grade, hormone receptor status and the Her 2 expression o f the tumor. There are many more pathological param eters which are yet to be included in the recommended list. Except for the age o f the patient all the other recommended prognostic and predictive factors mentioned are assessed by the pathologist. Therefore, the histopathology report is considered the gold standard to decide on the treatment o f breast cancer. Hormone receptor status o f breast cancer is an essential component o f surgical pathology report of a breast cancer as it decides the selection o f adjuvant hormonal therapy. Patients with hormone receptor positive breast cancers have a favourable response to endocrine therapy and improved survival. Hormone receptor expression of breast cancers in Sri Lanka is low and deviates from the global pattern. Only 32 to 53% o f breast cancer patients in Sri Lanka benefits from hormonal therapy. Measures at national level should be taken to increase the early detection o f breast cancer to improve the outcome as most o f our patients have aggressive tumours.