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
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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.
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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.