Discussion:
To our knowledge, this is the first article presenting a case of a man
who developed pneumocystis following adjuvant chemotherapy for early
breast cancer. Haut du formulaire
Bas du formulaire
A case of fatal pneumocystis was reported in Canada 12 years ago in a
patient undergoing first line Paclitaxel and Trastuzumab treatment for
bone metastatic breast cancer (2). The PJP diagnosis occurred after 8
cycles of chemotherapy over 7 weeks when the lymphocyte count was at its
lowest, measuring 400 cells/mm³. Susceptibility was attributed to
factors such as the use of dexamethasone and lymphocyte suppression.
Similarly, cases of PJP have emerged in breast cancer patients
undergoing docetaxel (3).
Recognized risk factors for pneumocystis, aside from HIV infection,
include prolonged use of corticosteroids (defined as >20mg
prednisone equivalent daily for > 4 weeks), low CD4 cell
counts, coexisting pulmonary diseases and recent chemotherapy (4,5).
Furthermore, having a solid tumor acts independently as a risk factor
for increased mortality related to PJP (6).
Following the observation of two cases of HIV-negative pneumocystis in
patients undergoing adjuvant chemotherapy for breast cancer, Tolaney et
al. initiated a prospective cohort study (7). Their investigation
revealed chemotherapy-induced lymphopenia during neoadjuvant or adjuvant
breast cancer treatment as a significant concern, notably around
5th cycle, associated with an elevated susceptibility
to opportunistic infections.
Current guidelines do not recommend systematic pneumocystis prophylaxis
during treatment for solid tumors, except for temozolomide chemotherapy
and prolonged use of corticosteroids (8).
This underscores the significance of implementing personalized medical
strategies, as exemplified in our case study, where factors extending
beyond the administration of Paclitaxel contribute to the risk ofPneumocystis jirovecii infection.
Otherwise, the effectiveness of adjuvant chemotherapy in elderly
individuals remains a subject of debate, prompting critical
consideration of its benefits and risks in this specific age group.
The APT trial conducted by Tolaney et al. published in 2015 included
10% of patients aged over 70 years in their cohort (1). Notably, within
this cohort, adverse events of grade 4 were observed in only 3 out of
406 patients, with no reported toxic deaths or severe infections.
A recent French propensity score-based study underscores the feasibility
of chemotherapy in elderly early breast cancer patients, highlighting
its potential for enhancing overall survival, and emphasizing the
importance of avoiding undertreatment based on age (9). Yet, in
accordance with the Breast Predict tool (10), incorporation of our
patient and tumor profiles implies that chemotherapy would have
conferred marginal benefit, with 68 out of 100 patients treated with
hormone therapy and trastuzumab surviving 5 years, compared to 69 out of
100 patients treated with chemotherapy, trastuzumab and hormone therapy,
yielding an increment of 1 additional survivor due to breast
cancer-related causes.
Haut du formulaire
Bas du formulaire
While adjuvant and neoadjuvant chemotherapies can reduce breast cancer
mortality, there is acknowledgment that they may also increase mortality
from other causes (11). Making an ideal treatment choice requires a
rigorous analysis that considers the trade-offs between benefits and
potential risks, encompassing the broader context of patient health and
the evolving landscape of medical progress.
This case emphasizes the importance of carefully assessing the benefits
and risks of adjuvant chemotherapy in frail patients, where the
potential benefits may be limited, and underscores the necessity of
vigilant monitoring to prevent potential opportunistic infections.