Simpulan Saran SIMPULAN DAN SARAN

kehilangan tiga siklus kemoterapi seharga limabelas juta rupiah bila neoajuvan kemoterapi gagal memberikan respon, itu untuk satu pasien. Di institusi SubBagian Bedah Tumor RSUP Sanglah Denpasar, rata – rata kemoterapi dikerjakan 10 – 15 pasien perminggu, jadi total biaya dibutuhkan sekitar 50 – 75 juta rupiah perminggu untuk satu siklus dan bila neoajuvan kemoterapi gagal memberikan respon, itu berarti terjadi kerugian kurang lebih 150 - 225 juta untuk setandar pemberian neoajuvan kemoterapi 3 siklus, itu belum termasuk biaya lain – lainnya seperti : biaya transportasi, pemondokan, kehilangan kerja dan konsumsi keluarga. Bila faktor untuk memprediksi respon dapat dipakai sebagai acuan terapi, maka biaya rata – rata dapat diselamatkan kira – kira 100 - 175 juta rupiah 2 siklus itu untuk biaya perawatan di institusi Sub Bagian Bedah Tumor saja, sedangkan pemberian kemoterapi di RSUP Sanglah Denpasar juga dikerjakan di Departemen lain. Sesuai dengan standar prosedur oprasional SOP penanganan kanker payudara, penelitian ini hanya menambahkan tindakkan core biopsy setelah kemoterapi siklus pertama dengan biaya relatif murah. Hal di atas menjadi penting untuk disikapi bagi pemegang kebijakan pengelola penjamin kesehatan seperti Badan Penyelenggara Jaminan Sosial kesehatan BPJS di Negara ini. Bila dilihat dari aspek psiko-somatososial, dampak efek samping obat kemoterapi menjadi beban berat setiap pasien khususnya pada pasien – pasien tidak mengerti tentang manfaat kemoterapi terhadap penyakitnya dan itu juga berdampak kurang baik terhadap kepatuhan pasien dengan aturan terapi. Merujuk dari hasil penelitian ini, maka permasalahan tersebut di atas dapat dikondisikan menjadi lebih baik.

5.6 Kebaruan Penelitian

Novelty Hal baru dapat dipetik pada penelitian observasional longitudinal prospektif atau kohort studi ini, tentang penurunan kadar mRNA caspase-3 dan Indek apoptosis pasca neoajuvan kemoterapi siklus pertama pada LABC yaitu: a. Dijumpai adanya hubungan linier atau sesuai dengan dogma sentral antara penurunan mRNA caspase-3 pasca neoajuvan kemoterapi 24 jam siklus pertama dengan penurunan ekpresi caspase-3 serta penurunan Indek apoptosis pada LABC. b. Penelitian ini dilakukan ditingkat terminal atau dihilir down stream pada proses apoptosis , sedangkan penelitian – penelitian lain umumnya dilakukan dihulu upstream dalam proses apoptosis. c. Penelitian observasi uji klinis ini dilakukan pada manusia sebagai subjek penelitian sedangkan penelitian di beberapa negara pada umumnya dilakukan pada binatang coba dan sel kultur d. Penurunan mRNA caspase-3 dan Indek apoptosis pasca neoajuvan kemoterapi siklus pertama secara signifikan berhubungan dengan penurunan respon kemoterapi dan dapat dipakai sebagai faktor prediktor respon kemoterapi pada LABC.

6. SIMPULAN DAN SARAN

6.1 Simpulan

Rancangan penelitian longitudinal prospektif atau kohort studi non – ekperimental analitik ini dipergunakan untuk membuktikan peranan mRNA caspase-3 dan Indeks apoptosis sebagai faktor risiko respon neoajuvan kemoterapi pada LABC. Dapat diambil simpulan : a. Penurunan kadar mRNA caspase-3 setelah pemberian neoajuvan kemoterapi 24 jam siklus pertama mempunyai hubungan bermakna dengan respon kemoterapi negatif pada LABC. Jadi dapat dipakai sebagai parameter atau faktor prediktor untuk menilai ada tidaknya respon kemoterapi pada Locally Advanced Breast Cancer LABC. b. Penurunan Indeks apoptosis setelah pemberian neoajuvan kemterapi 24 jam siklus pertama mempunyai hubungan bermakna dengan respon kemoterapi negatif pada LABC. Jadi dapat dipakai sebagai parameter atau faktor prediktor untuk menilai ada tidaknya respon kemoterapi pada Locally Advanced Breast Cancer LABC. c. Indeks apoptosis sebagai risiko respon kemoterapi negatif lebih kuat dibandingkan dengan mRNA caspase-3 pada Locally Advanced Breast Cancer LABC. d. Terdapat hubungan linier antara penurunan Indeks apoptosis dengan penurunan kadan mRNA caspase-3.

6.2 Saran

a. Rancangan penelitian observasional kohort ini, merupakan studi epidemiologis analitik non - ekperimental dengan mempelajari hubungan antara faktor risiko dengan efek atau suatu penyakit, maka hasil penelitian ini dapat dipertimbangkan sebagai acuan untuk menilai respon kemoterapi pada pasien LABC. Berlatar belakang pada penelitian ini, caspase-3 sebagai caspase eksekutor down stream pada proses apoptosis bekerja dalam sitoplasma bukan molekul protein langsung masuk ke dalam inti sel dan merusak DNA, tetapi memerlukan molekul lain mampu masuk dan merusak DNA ke dalam inti sel yaitu CAD DFF40. Maka dari itu perlu dilakukan penelitian lanjutan tentang adanya melekul – molekul lain lebih berperan dalam proses apoptosis. b. Untuk meningkatkan level penelitian ini, perlu dipertimbangkan untuk dilakukan penelitian multi senter. DISSERTATION RESUME DECREASE OF mRNA CASPASE-3 AND APOPTOSIS INDEX LEVEL AFTER FIRST CHEMOTHERAPY CYCLE AS PREDICTORS FOR NEGATIVE CHEMOTHERAPY RESPONSE IN LOCALLY ADVANCED BREAST CANCER 1. INTRODUCTION Breast cancer was a common malignancy found in women and its prevention and management have been an issue worldwide. Breast cancer was the second cause of cancer mortality in women after lung cancer worldwide. There were 429,900 new breast cancer cases and more than one million women was diagnosed with breast cancer with a mortality rate over 100,000 annually in the European Union in 2006. While in the United States of America, there were 274,900 new cases with a mortality rate of 40,970 annually in 2006. In ASEAN countries, breast cancer contributed to 22 malignances in women and was the cause of 15 cancer related mortality in 2008. American Joint Committee on Cancer AJCC found there has been a marked increase in stage I and II breast cancer incidence 75 - 80 in developed countries, this was probably due to the advances in mammography screening program Zager, et al ., 2006; Abeloff, et al ., 2008; Kwon , et al., 2010; Burstein, et al ., 2011; Kimman, et al ., 2012. Early Breast Cancer EBC had higher survival rate and lower recurrence rate compared to Locally Advanced Breast Cancer LABC. The incidence of LABC in United States of America was less than 5 for women who actively enrolled in screening programs, while women who did not have access to screening programs had 40 - 60 incidence rate. The incidence rate of LABC among developing countries did not vary much, India had an incidence rate of 50-70, Arab had an incidence rate of 60-80 with 300.000-450.000 new cases estimated annually. Locally Advanced Breast Cancer was estimated to be over than 50 of cases in Indonesia. In Bali, LABC had an incidence rate of 76.3 of breast cancer cases in 2010 Lee and Newman, 2007; Hortobagyi, et al., 2010; Manuaba, 2010; Saghir, 2011. Locally Advanced Breast Cancer was a subgroup of breast cancer with high heterogenity, large primary tumor with lymph node involvement and without any distant metastasis. Around 25-30 cases of LABC were inoperable Lee and Newman, 2007; Sobin, et al ., 2009; Kwon , et al., 2010 . The main treatment modality for LABC had been surgery, but there have been major changes in breast cancer management since the early 1970s. There was a paradigm shift on breast cancer management and it has been accepted that breast cancer was a systemic disease where patient survival was determined by micrometasis eradication, therefore multimodality treatment approaches have been accepted and developed for LABC. Loco-regional and systemic treatment modalities, such as chemotherapy, have been the treatment of choice and the standard for LABC management Zager, et al .,2006; Hortobagyi, et al ., 2010. Neoadjuvant chemotherapy NAC played a pivotal role as standard therapy for LABC and needs to be optimized. Unfortunately, several clinical trial studies showed varied results on the role of NAC in LABC. Some prospective studies on the role of NAC in LABC showed that 50-98 had Partial Response PR, 5-52 had Complete Clinical Response cCR, and 4-28 had Pathological Complete Response pCR Dang and Hudis, 2010; Hortobagyi, et al., 2010. Manuaba 2006 found that only 39,4 LABC patients showed positive NAC response while 60,6 patients showed negative NAC response. The results showed that the purpose of NAC to reduce tumor size and eradicate tumor cells only occurred in 39,4 patients, while 60,6 patients will have a stable or progressive disease. This of course was a significant issue in the management of LABC. A cohort study of 205 LABC patients treated with anthracycline based NAC showed 60 of the samples had negative response and 40 had positive response. From the 40 that had positive NAC response, 12 showed Complete Clinical Response cCR, 28 showed Clinical Partial Response cPR, and 8 showed Pathological Complete Response pCR Alvarado-Cabrero, et al ., 2009. Other similar clinical studies found that anthracycline based NAC in LABC had 60-90 positive response with 10-20 Complete Clinical Response cCR Hortobagyi, et al ., 2010. Tewari, et al 2010 found 78 positive response 64 PR and 14 cCR and 22 negative response, while Gianni, et al 2010 found 74 positive response and 26 negative response in LABC patients treated with NAC. Another study found 77,5 positive response and 22,5 negative response Torrisi, et al ., 2010. The decrease in NAC response will reduce the role of surgery as the main treatment modality in order to minimize physical and psychological effects as in breast conserving therapy. Breast Conserving Therapy BCT was intended for organ preservation and its role was limited in LABC where 40-50 patients will need further treatment. Furthermore, in NAC unresponsive LABC patients often experience delayed treatment or inadequate treatment. These conditions will reduce the Disease Free Survival DFS or Overall Survival OS in more than 40 of the cases and will cause ineffective chemotherapeutic effects and side effects. Therefore, it is important to predict the chemotherapy response in LABC patients. All of those issues could be calculated and managed, if we could identify the biomolecular predictive markers for NAC responsiveness in LABC patients. These biomarkers will be useful in determining NAC response before the end of chemotherapy cycle Hortobagyi, et al ., 2010. Several biomarkers have been identified for NAC response HER2Neu, proliferation factor Ki67, estrogen and progesterone receptor status, angiogenesis factor VEGFVEGFR, p53, p21, and apoptosis components Bcl-2 and BAX. Unfortunately, not more than 29 of those biomarkers are able to predict chemotherapy response specifically and consistently due to limited data on LABC Zager, et al ., 2006; Abeloff, et al., 2008; Rastogi, et al., 2008; Biganzoli, 2009; Hortobagyi, et al ., 2010; Tewari, et al ., 2010. Other biomarkers associated with post NAC cell death such as mRNA- Caspase and its products enzymes played a role in the terminal phase of cell death. These proteases will become active inside the cytoplasm after tumor cells were exposed to cytotoxic agents such as chemotherapy, radiation, and other cytotoxic agents. Caspase-3 in particular, a protease translated by mRNA-Caspase 3 will adhere to the terminal downstream strand in the apoptosis cascade. Caspase-3 holds a key role in the apoptosis cascade known as effectorexecutor caspase which yields Apoptosis Index as the end result Dorsey, et al ., 2008; Elstrom and Thompson, 2008 . Apoptosis index is measurable 4-8 hours post chemotherapy and an increase in apoptosis will occur 24-48 hours after. A study revealed that apoptosis will increase on the 21 st day post chemotherapy and significantly related to a positive chemotherapy response. But apoptosis index evaluation on the 21 st day post chemotherapy were considered late to determine chemotherapy response, therefore ideally a serial biopsy is needed to determine the apoptosis index accurately during chemotherapy, especially in negative response cases. Serial biopsy is practically unfavorable for LABC patients. Therefore, apoptosis index level evaluation after 24-48 hours post NAC was desirable. Based on NAC mechanism of action in apoptosis cascade with Caspase 3 as an effectorexecutor, it was needed to explore and reveal the role of mRNA-Caspase 3 and its end product Apoptosis Index as a predictive biomarker for NAC response in LABC Burcombe, et al ., 2005; Sharma, et al., 2009. Manuaba 2006 found that apoptosis index and Bcl-2 expression were predictive factors for CAFCEF NAC response in LABC. A preliminary study by Shama et al on the role of Bcl-2, apoptosis index, and Caspase-3 as predictive factors for NAC response 24-48 hours post chemotherapy showed a tendency for those biomarkers as predictive factors, but statistically insignificant. Another study showed a significant relationship between apoptosis index with positive chemotherapy response after the first cycle of NAC in LABC Ali, et al., 2012 . 2. HYPOTHESIS Locally Advanced Breast Cancers have unpredictable biological nature and behavior, therefore a comprehensive approach is important to determine the therapeutic multimodality. The purpose of using NAC in LABC was to optimize the role of surgery as main treatment modality. One of the main issues in LABC management was negative NAC response. Several predictive factors have been identified for NAC response in LABC, such as age, tumor size, histological grade, histopathological type, and several biomarkers Estogen and Progesteron Receptor status, HER2Neu expression, proliferation factor Ki67, angiogenesis factor VEGFVEGFR, p53, pro and anti apoptosis factors Bcl-2 and BAX. Only 29 of those biomarkers are able to predict chemotherapy response specifically and consistently. Apoptosis, a mechanism used to maintain normal tissue or organ growth, was studied as a predictor for NAC response. This mechanism held a key role in tumorigenesis and therapeutic response. Therefore it is of utmost importance to be able to determine apoptosis activity during chemotherapy in LABC. Novel biomarkers mRNA Caspase-3 and Apoptosis Index have been studied to determine NAC response. These biomarkers were potential predictive factors for NAC response in LABC. The ability to determine NAC response was important to prevent delay in LABC management. Therefore, morbidity and mortality from inadequate LABC management could be reduced. Figure 1 Research Concept Based on the research concept, two research hypothesizes were determined: 1. Decrease in mRNA Caspase-3 post first cycle NAC is a negative predictive factor for NAC in LABC. 2. Increase in mRNA Caspase-3 post first cycle NAC is a positive predictive factor for NAC in LABC.

3. PATIENTS AND METHODS