Depths of Malignancy: On the Prognosis of Breast Cancer [Letter]

Dear editor

We have read the article by He et al¹ with great interest and we appreciate and congratulate the authors on their findings of a single independent prognostic factor in breast cancer. Breast cancer is an emerging disease worldwide, and claims the lives of many women each year. Hence, identifying better prognostic factors for breast cancer has now become the need of time.

In the inclusion criteria of this study, the authors mentioned that 134 Xanthous females with breast cancer were included. Apart from this, it should be considered whether the female participants were lactating or not, as lactation can prove to be a confounder as well as a positive prognostic factor. Studies have shown a negative association between lactation and breast cancer, so lactating women are less likely to develop breast cancer and even if they get the disease, they have a better prognosis as compared to non-lactating women.²

Although lactate dehydrogenase to albumin ratio (LAR) can be used as a single prognostic factor in breast cancer patients, the validation of this outcome is questionable due to single-time evaluation pre-operatively.

The authors studied progression-free survival among breast cancer patients based on a combination of different immune and inflammatory biomarkers. However, C-reactive protein which is a vital inflammatory marker is not mentioned, but if considered could have a big influence on the results of this study. Moreover, different studies proved a high association of C-reactive protein with breast cancer.³

In this study, for assessing inflammatory markers, blood was selected as a medium. Breast tissue is extensively drained by the lymphatic system. Assessing inflammatory markers from lymphatic drainage, like fine-needle aspiration of lymphatic fluid, can provide valuable information about the presence and progression of breast cancer. Studies have shown that lymphatic assessment gives more reliable results in predicting overall survival in breast cancer patients.⁴

The authors followed up the cases for progression-free survival until 45 months after surgery, which is less than 4 years. A period of this duration just means that the said prognostic biomarkers could prove to be good independent prognostic factors in terms of causing remission for less than 4 years. However, it is still open to debate if the prognostic factors of platelet count to lymphocyte count ratio, monocyte count to lymphocyte ratio, and LAR have a curative value or not, which requires at least 5 years of follow-up.