the clinical application of evidence based clinical practice.Breast cancer indications of treatment Based on high level evidence .and colon cancer adjuvant chemotherapy .the effect of adjuvant chemotherapy in certain stages and the survival benefit for stages of colon cancer ,stage II and Stage III as reveled by MOSAIC TRIAL AND Early Breast Cancer Trialists' Collaborative Group (EBCTCG) Meta-analysis.the high level evidence always relies on the meta analyses and phase III of well designed randomized controlled clinical trials.

1. EVIDENCE BASED
CANCER CARE
(EBCC)
Interactivecasesdiscussion
2019
Dr Mona Quenawy
Dr Hagar El Ghazawy

2. Case 1

3. HISTORY & EXAMINATION
-Mr A.M. is 33-year-old years male, was hospitalized because of acute abdominal pain, melena, and
vomiting.
-No weight loss or other specific symptoms were present. before the onset of the symptoms
-He did not have any chronic diseases and had no family history of malignancy.
-O/E: -ECOG:1
-distended abdomen and decreased bowel sounds were observed.
-diffuse tenderness was present throughout the abdomen.
-No other signs

4. Workup:
-Abdominal CT scan confirmed the presence of rt sided colonic lesion with distal segmental ischemic changes
-Colonoscopy & Bx: Rt sided colonic cancer
-CT chest : NAD
Surgical resection: RT hemicolectomy:
Histopathology confirms adenocarcinoma grade II , mucinous variant with LVI and PNI , LN 8/15
pathological T3N2Mx
staging confirms stage III colon cancer

5. Further management ???
1- keep patient on follow up
2- cetuximab
3 –adjuvant chemotherapy for 6 months
4- nivolumab

6. Based on:
In MOSAIC, patients with stage II or III disease were randomly assigned to receive
adjuvant FOLFOX4 or 5-FU/leucovorin.
After a median follow-up of 9.5 years, 10-year overall survival among all 2,246 patients
was 67.1% vs 59.0% in those with stage III disease (P = .016).

7. Case 2

8. History & clinical ex:
■ 45 ys old female patient, No comorbidities, irrelevant F.H
■ C/O: Painless Rt breast lump, of 2 mns duration
■ O/E: -ECOG1
-Rt upper quadrant mobile mass
- No palpable axillary/SCV LNs
-No other signs

9. Workup & management
■ Sono-mammogram: Rt breast mass, 3x4cm, Reactionary axillary LNs
■ Tru-cut Bx of the breast mass: IDC, Gr.2
■ IHC: ER =6/8, PR=5/8, Her2-ve, Ki67=30%
■ CXR, PA-U/S : NAD
■ RT BSC
-IDC, Gr 2, free margins
-LN=3/12
-pT2 N1
■ Then pt finished 6 cycles of chemotherapy (ANTs/Taxanes)

10. Further management ???
1- No need for Radiotherapy
2- Start radiotherapy to whole breast

11. Based on :
■ Early Breast Cancer Trialists' Collaborative Group (EBCTCG) Meta-analysis
-included 17 RCT, (10 801 patients)
-Trials randomized pts after BCS to RTh vs no Rth
-Rth resulted in: -reduced 15-year risk of BC death from 25·2% to 21·4% (absolute reduction 3·8%, p=0·00005).
- In pN+ disease :
Rth reduced the 10-y recurrence risk from 63·7% to 42·5% (absolute reduction 21·2%, p<0·00001)
and the 15-y risk of breast cancer death from 51·3% to 42·8% (absolute reduction 8·5%, p=0·01)