Cancro al seno. Un test genomico per scegliere la terapia corretta. Ma in Italia non si usa

Pubblicato il 29 Novembre 2012 da AndosVelletri

Approvato in tutta Europa e usato negli Usa, Oncotype DX è capace di distinguere i tumori che necessitano di chemioterapia da quelli in cui il trattamento costoso e dai pesanti effetti collaterali può essere evitato. In Italia viene usato pochissimo, anche perché il Ssn non lo rimborsa.

È già stato approvato e viene usato negli Stati Uniti e in alcuni paesi europei, ma il test genomicoOncotype DX per il tumore al seno fa ancora fatica a prendere piede in Italia. Si tratta di un’analisi personalizzata che studia 21 geni specifici (16 correlati al tumore e 5 di riferimento), la loro interazione e funzionalità, ed è così in grado di distinguere i tumori a bassa probabilità di dare recidive, e dunque trattabili con la sola terapia ormonale, da quelli che invece devono essere trattati con chemioterapia. Così permette di capire subito quale sia il migliore trattamento adiuvante possibile, e dunque di risparmiare terapie inutili e dagli effetti collaterali pesanti. Ma allora perché nel nostro paese viene usato poco? Questione di costi, dicono gli esperti. In Italia il test è infatti già disponibile, come in tutta l’Europa (marcatura CE), ma non è ancora rimborsato dal Sistema sanitario nazionale. Per questo esso viene utilizzato sporadicamente, oltre che in alcuni studi clinici, da alcune pazienti che provvedono direttamente al suo pagamento.


Un test effettuabile in qualsiasi momento su un campione di tessuto tumorale prelevato durante l’intervento chirurgico originale (asportazione del nodulo, mastectomia, biopsia mammaria), indicato in caso di tumori in stadio precoce con recettori positivi per l’estrogeno (ER+) o per il progesterone (PgR+) e linfonodi negativi e nelle pazienti in postmenopausa ER+ e con 1-3 linfonodi positivi. L’Oncotype DX – questo il nome del test genomico – è stato validato su 5 mila donne, approvato a livello internazionale ed è previsto dalle linee guida come complemento dei criteri decisionali tradizionali sia da St. Gallen® sia dalle maggiori società internazionali, quali American Society of Clinical Oncology (ASCO)®, National Comprehensive Cancer Network (NCCN)® e European Society of Medical Oncology (ESMO) quale effettivo ausilio per l’oncologo. Gli studi condotti in Francia, Germania, Spagna e Regno Unito hanno dimostrato che l’impiego del test è in grado di modificare la strategia terapeutica adiuvante in un terzo circa delle pazienti e nella pratica clinica americana, dove è di uso corrente, ha ridotto l’utilizzo della chemioterapia dal 63% nel 2006 al 45% nel 2009.
 
Il test – spiegano gli esperti – ha la potenzialità di poter rivoluzionare sia l’approccio terapeutico, sia la scelta della paziente garantendo la certezza di una cura “su misura”, in relazione all’attività biologica del tumore: aiuta il medico a selezionare le candidata ‘giusta’ alla somministrazione di chemioterapia attraverso la misurazione di un ‘recurrence score’, un numero corrispondente alla specifica probabilità di recidiva di un tumore al seno, entro 10 anni dalla diagnosi iniziale.  Aspetto, quest’ultimo, non trascurabile se si considera che in Italia sono oltre 40 mila i nuovi casi di tumore della mammella all’anno, 152 ogni 100 mila donne, con la probabilità che 1 donna su 10 possa esserne colpita nell’arco della vita. Ad oggi, nel mondo, sono stati richiesti oltre 275 mila test da più di 10 mila clinici in 70 Paesi.
L’analisi fornisce indicazioni terapeutiche strategiche quando i criteri abituali (età, dimensione del tumore, performance status, interessamento linfonodale, recettori) non indicano una sicura condotta da adottare. In un terzo delle pazienti sottoposte ai test in fase di validazione, l’oncologo ha potuto modificare il piano terapeutico evitando la chemioterapia in un quarto e aggiungendola nel 5-10% delle pazienti stesse. A garanzia dell’accuratezza diagnostica, vi è una misurazione (effettuata separatamente 3 volte) sui 21 geni in ogni campione tissutale e trials clinici effettuati su oltre 4 mila donne. Valore aggiunto, è anche la capacità predittiva che consente di stimare le probabilità di recidiva nell’arco dei successivi dieci anni misurata attraverso il ‘recurrece score’ (RS, un valore compreso tra 0 e 100), che ne determina anche il gruppo di rischio: basso (RS <18), intermedio (RS tra 18-30), elevato (RS>31).
 
Eppure, in Italia ancora non viene usato quanto potrebbe. “Nel nostro come in altri paesi il limite all’utilizzo dei più recenti test genomici è rappresentato dai costi in quanto, non essendo il test rimborsato dal sistema sanitario, sono a carico dei singoli pazienti”, ha spiegato Giampaolo Bianchini, oncologo presso il Dipartimento di Oncologia Medica del San Raffaele di Milano. Come risolvere il problema dunque? “Sono dell’opinione che il Sistema Sanitario Nazionale del nostro paese, insieme agli organi istituzionali preposti e ai comitati scientifici italiani, in primis dell’AIOM, dovrebbero riunirsi intorno a un tavolo e valutare i potenziali vantaggi che in termini di costo-beneficio la rimborsabilità del test potrebbe portare, magari tenendo conto delle esigenze di contenimento dei costi nel sistema sanitario nazionale, identificando quei sottogruppi candidabili nei quali il rapporto costo-beneficio risulta persino più elevato”, ha spiegato Bianchini. “Tali vantaggi non sono identificabili soltanto nella possibilità di evitare le tossicità di un trattamento chemioterapico con un impatto ovvio in termini di qualità della vita senza ridurre le probabilità di guarire dal carcinoma mammario, ma anche, in una visione di contenimento dei costi, nella riduzione del costo di farmaci ed impiego delle risorse sanitarie nonché in termini di riduzione delle giornate di lavoro perse. Comunque, i vantaggi in termini di impatto sulla qualità della vita, sono i più importanti e non possono essere strettamente misurati dal punto di vista del guadagno o del risparmio economico”.

Fonte: “Quotidiano.it” – 29 novembre 2012

Questa voce è stata pubblicata in News e contrassegnata con , , , . Contrassegna il permalink.

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