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Old 01-08-2014, 02:11 PM   #1
Hopeful
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HER2/HR positive early breast cancer patients have the highest disease-free survival

Abstract: http://www.abstracts2view.com/sabcs1...u=SABCS13L_903

Poster: http://www.abstracts2view.com/sabcs1...hp?nu=P3-06-05

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Old 01-08-2014, 08:16 PM   #2
'lizbeth
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Re: HER2/HR positive early breast cancer patients have the highest disease-free survi

I would expect these patients were not treated with Herceptin?
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Old 01-09-2014, 07:35 AM   #3
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Re: HER2/HR positive early breast cancer patients have the highest disease-free survi

'lizbeth, I believe they were treated with Herceptin - the abstract states:

Quote:
we aimed to assess the outcome of early breast cancer patients per subtype based on HER2 and HR status in daily practice treated in a time period of routine use of anti-HER2 treatment.
(emphasis added).

The time frame covered was 2005- 2007.

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Old 01-09-2014, 09:51 AM   #4
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Re: HER2/HR positive early breast cancer patients have the highest disease-free survi

Thanks Hopeful, I see this article in the References - and it mentions trastuzumab, so I would guess that anti-Her2 means Herceptin.




Strategies for subtypes—dealing with the diversity of breast cancer: highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2011

  1. A. Goldhirsch1,*,
  2. W. C. Wood2,
  3. A. S. Coates3,
  4. R. D. Gelber4,
  5. B. Thürlimann5,
  6. H.-J. Senn6,
  7. Panel members
+ Author Affiliations
  1. 1International Breast Cancer Study Group, Department of Medicine, European Institute of Oncology, Milan, Italy
  2. 2Department of Surgery, Emory University School of Medicine, N. E. Atlanta, USA
  3. 3International Breast Cancer Study Group and University of Sydney, Sydney, Australia
  4. 4International Breast Cancer Study Group Statistical Center, Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA
  5. 5Breast Center, Kantonsspital St Gallen, St Gallen
  6. 6Tumor and Breast Center ZeTuP, St Gallen, Switzerland
  1. *Correspondence to: Prof. A. Goldhirsch, International Breast Cancer Study Group, Department of Medicine, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy. Tel: +39-02-57489439; Fax: +39-02-94379273; E-mail: aron.goldhirsch@ibcsg.org;
  • Received April 21, 2011.
  • Accepted May 23, 2011.


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Abstract

The 12th St Gallen International Breast Cancer Conference (2011) Expert Panel adopted a new approach to the classification of patients for therapeutic purposes based on the recognition of intrinsic biological subtypes within the breast cancer spectrum. For practical purposes, these subtypes may be approximated using clinicopathological rather than gene expression array criteria. In general, systemic therapy recommendations follow the subtype classification. Thus, ‘Luminal A’ disease generally requires only endocrine therapy, which also forms part of the treatment of the ‘Luminal B’ subtype. Chemotherapy is considered indicated for most patients with ‘Luminal B', ‘Human Epidermal growth factor Receptor 2 (HER2) positive’, and ‘Triple negative (ductal)’ disease, with the addition of trastuzumab in ‘HER2 positive’ disease. Progress was also noted in defining better tolerated local therapies in selected cases without loss of efficacy, such as accelerated radiation therapy and the omission of axillary dissection under defined circumstances. Broad treatment recommendations are presented, recognizing that detailed treatment decisions need to consider disease extent, host factors, patient preferences, and social and economic constraints.

Key words

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introduction

It is no longer tenable to consider breast cancer as a single disease. Subtypes can be defined by genetic array testing [13] or approximations to this classification using immunohistochemistry [47]. These subtypes have different epidemiological risk factors [8, 9], different natural histories [1012], and different responses to systemic and local therapies [1317]. These differences imply that clinicians managing breast cancer should consider cases within the various distinct subtypes in order to properly assess the relevant evidence and arrive at appropriate therapeutic advice.

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St Gallen 2011: news and progress

The 12th International Breast Cancer Conference in March 2011 brought together some 4300 participants from 96 countries and a worldwide faculty representing all relevant disciplines. After presentation of recent research findings, a 51-member Expert Panel (see Appendix 1) considered a number of questions in order to arrive at treatment recommendations for the immediate future. As in previous St Gallen conferences [18], the Panel was charged with assessing the evidence, but also advising on the basis of expert opinion on those questions where the evidence was ambiguous or lacking. For the first time, this conference included an explicit approach to management of conflicts of interest (see Appendix 2).
Evidence was presented to support a less aggressive approach to axillary surgery in defined circumstances and the use of more convenient equally effective approaches to radiation therapy. For systemic therapy, the emphasis of this year’s consensus was to reach recommendations within each of the biological subtypes, since these already incorporate many of the risk factors and response predictors previously considered separately. Disease extent, host factors, patient preferences, and economic and social factors inevitably impact the choice and delivery of care. In general, the recommendations are intended to guide therapy considerations outside clinical trials in communities with reasonable levels of available resources, but noting where possible the availability of alternatives, which might be only marginally less effective but less expensive.
This report will first review the new findings presented at the meeting (Table 1) and then proceed to summarize the deliberations of the Panel, bringing these together to form broad therapy recommendations.
View this table:

Table 1. Recent research findings presented at the 12th International Conference on Primary Therapy of Early Breast Cancer and their implications for patient care


local therapies

New results from clinical trials supported the safety of omitting axillary dissection not only in patients with a negative sentinel node biopsy [19] but also in patients with a clinically node-negative axilla but pathological macrometastatic involvement of one or two sentinel nodes in the context of breast-conserving surgery with tangential field radiation therapy [20]. This continues a trend of reduced surgical extent without loss of efficacy, which dates back to the breast-conserving approaches pioneered by Veronesi [74] and Fisher [75].
Similarly, recent studies in radiation therapy have demonstrated the safety and efficacy of abbreviated schedules for improved patient convenience and the use of partial breast irradiation (PBI) under certain defined circumstances. These findings are summarized in Table 1.

breast cancer subtypes

Analysis of gene expression arrays has resulted in the recognition of several fundamentally different subtypes of breast cancer [1]. Because it is not always feasible to obtain gene expression array information, a simplified classification, closely following that proposed by Cheang et al. [7], has been adopted as a useful shorthand. Subtypes defined by clinicopathological criteria are similar to but not identical to intrinsic subtypes and represent a convenient approximation. As summarized in Table 2, this approach uses immunohistochemical definition of estrogen and progesterone receptor, the detection of overexpression and/or amplification of the human epidermal growth factor receptor 2 (HER2) oncogene, and Ki-67 labeling index, a marker of cell proliferation, as the means of identifying tumor subtypes.
View this table:

Table 2. Surrogate definitions of intrinsic subtypes of breast cancer (4, 7)


Clearly, this clinicopathological classification requires the availability of reliable measurements of its individual components. Guidelines have been published for estrogen and progesterone receptor determination [76] and for the detection of HER2 positivity [77]. For clinical decision making, the Panel supported using the US Food and Drug Administration definition of HER2 positivity based on the eligibility criteria for HER2 status determination from the pivotal clinical trials [80, 81]. It was noted that clarifications to the ASCO/CAP guidelines were in preparation, and these have subsequently been published [82]. Ki-67 labeling index presents more substantial challenges, but important guidelines for this test are under development [7, 8385]. In the proposed classification, Ki-67 labeling index is chiefly important in the distinction between ‘Luminal A’ and ‘Luminal B (HER2 negative)’ subtypes. If reliable Ki-67 labeling index assessment is not available, some alternative measure of proliferation such as a histological grade may be used in making this distinction.


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panel deliberations

More than 100 questions were circulated and agreed among Panel members before the meeting. These were presented during the final session of the conference. Panel members had the opportunity to comment, and then voted electronically either yes or no on each question, with the option to abstain if they felt uninformed or conflicted. The detailed votes are not presented here: Rather, verbal descriptions of the extent of agreement or disagreement are given in the following sections.
axillary surgery

The Panel was clearly of the view that the routine use of immunohistochemistry to look for low-volume metastatic disease in sentinel nodes was not indicated, since metastases shown only by immunohistochemistry would not alter management. Furthermore, isolated tumor cells, and even metastases up to 2 mm (micrometastases) in a single sentinel node, were not considered to constitute an indication for axillary dissection regardless of the type of breast surgery carried out. The Panel accepted the option of omitting axillary dissection for macrometastases in the context of lumpectomy and radiation therapy for patients with clinically node-negative disease and 1–2 positive sentinel lymph nodes as reported from ACOSOG trial Z0011 with a median follow-up of 6.3 years [20]. The Panel, however, was very clear that this practice, based on a specific clinical trial setting, should not be extended more generally, such as to patients undergoing mastectomy, those who will not receive whole-breast tangential field radiation therapy, those with involvement of more than two sentinel nodes, and patients receiving neoadjuvant therapy.

radiation therapy

The Panel considered accelerated whole-breast radiotherapy to be an acceptable option in select patients: In particular, the Panel was divided about the use of this approach in the presence of extensive vascular invasion.
Partial breast irradiation (PBI) as definitive treatment in selected patients was supported by almost half of the Panel and by a strong majority for patients above the age of 70. There was considerable uncertainty about its use in lymphoma survivors who had previously undergone mantle field irradiation, where out-of-quadrant second cancers’ risks are considerable and for any patient groups different from the current eligible population in PBI trials. The Panel generally accepted PBI as an alternative to conventional external beam boost to the tumor bed.
Post-mastectomy radiation therapy was strongly supported for patients with four or more axillary lymph nodes involved. While not in general favoring irradiation for those with lesser nodal involvement, the Panel by a slim majority favored post-mastectomy radiation for patients younger than 45 years with 1–3 positive nodes and for patients at any age with extensive vascular invasion in two or more blocks in conjunction with 1–3 positive nodes.
A majority of the Panel supported radiation after complete excision of ductal carcinoma in situ (DCIS) but was prepared to countenance its omission for some elderly patients and those with low-grade low-risk DCIS.

definition of biological subtypes

The Panel strongly supported the clinicopathological determination of estrogen receptor, progesterone receptor, HER2, and Ki-67 as useful for defining subtypes, but did not support the incorporation of tests for cytokeratin 5/6 or epidermal growth factor receptor/HER1 for the determination of ‘basal-like’ tumors for clinical decision making. The endorsed clinicopathological criteria define a convenient alternative to formal subtyping and are likely to be refined in the future. The Panel did not require multigene array definition of tumor subtype, although there was acceptance of such assays for certain indications (see below). However, the Panel did recommend that the clinicopathological markers described above were generally sufficient to guide therapeutic choices.

selection of endocrine therapy in premenopausal women

The Panel accepted tamoxifen alone or ovarian function suppression plus tamoxifen as reasonable, though expressing a preference for tamoxifen alone. In patients with a contraindication to tamoxifen, ovarian function suppression alone was accepted as a treatment, while the combination of ovarian function suppression plus an aromatase inhibitor was also considered reasonable.

selection of endocrine therapy in postmenopausal women

The Panel was exactly equally divided about whether all postmenopausal patients should receive an aromatase inhibitor (if available and not contraindicated) at some point in treatment, but was more supportive of aromatase inhibitors in the presence of involved lymph nodes. A large majority felt that selected patients could be treated with tamoxifen alone, and that patients could be switched to tamoxifen if intolerant to aromatase inhibitors. The Panel stressed the need to ensure that patients receiving an aromatase inhibitor were indeed postmenopausal, whether by clinical or biochemical criteria.
The Panel considered that 5 years of an aromatase inhibitor was a sufficient duration and a majority opposed extension even in the presence of node-positive disease or among younger postmenopausal patients (<55 years of age). The Panel was almost unanimous in rejecting CYP2D6 testing to dictate choice of endocrine therapy type.

chemotherapy

The Panel agreed that factors arguing for the inclusion of chemotherapy were high histological grade, high proliferation as measured by Ki-67, low hormone receptor status, positive HER2 status, and ‘Triple negative’ status in invasive ductal carcinoma of usual forms. These factors are largely captured in the tumor subtype definitions summarized in Table 2. There was a lack of complete consensus on the threshold indication for inclusion of chemotherapy for patients with ‘Luminal A’ or ‘Luminal B (HER2 negative)’ disease. In terms of disease extent, the Panel did not believe that node positivity per se was an indication for use of chemotherapy, though a strong majority would use it if more than three lymph nodes were involved.
Several tests are available which define prognosis [57, 58, 86]. These may indicate a prognosis so good that the doctor and patient decide that chemotherapy is not required. A strong majority of the Panel agreed that the 21-gene signature (Oncotype DX®) [57] may also be used where available to predict chemotherapy responsiveness in an endocrine-responsive cohort where uncertainty remains after consideration of other tests, but the majority agreed that the chemopredictive properties of the 70-gene signature (MammaPrint®) [58] were not yet sufficiently established. Trials are ongoing to clarify this role for both tests. The majority of the Panel did not support lymphovascular invasion as a sufficient indication for chemotherapy, and less than a quarter of the Panel supported uPA/PAI1 [86] as a predictive marker for the use of chemotherapy.

chemotherapy in subtypes

The Panel strongly agreed that the ‘Luminal A’ subtype was less responsive to chemotherapy; that chemotherapy was less useful in such patients; and that no preferred chemotherapy regimen could be defined for treatment of ‘Luminal A’ disease.
For ‘Luminal B’ disease, the Panel considered that both anthracyclines and taxanes should be included in the chemotherapy regimen. While the Panel could not define a single preferred chemotherapy regimen for ‘HER2 positive’ disease, the majority again favored the inclusion of both anthracyclines and taxanes. For ‘Triple negative’ disease of the usual ductal type, the Panel again supported the inclusion of anthracyclines and taxanes and an alkylating agent (typically cyclophosphamide), but did not support the routine use of cisplatin or carboplatin. A slim majority agreed that dose-dense chemotherapy [87] should be considered for such patients, and the Panel was strongly opposed to the inclusion of antiangiogenic therapies at this time, while noting that further trials are ongoing.

trastuzumab

The Panel unanimously supported the use of 1 year of trastuzumab as standard adjuvant treatment for patients with ‘HER2 positive’ disease, and the majority were willing to extend this to patients with pT1b, but not pT1a pN0 disease. Trastuzumab administered for <1 year [88] was regarded as suboptimal if 1 year of therapy was feasible, but better than no trastuzumab if limited resources prevented its full duration use. While awaiting data from the ongoing HERA trial, the Panel did not support continuation of adjuvant trastuzumab beyond 1 year. While preferring that trastuzumab be initiated concurrently with chemotherapy, the Panel also accepted its sequential use. The Panel did not support the use of trastuzumab without chemotherapy if chemotherapy could be given, but was prepared to countenance such treatment in circumstances where chemotherapy could not be delivered.

neoadjuvant cytotoxic therapy

A majority of the Panel considered that neoadjuvant cytotoxic therapy was of value beyond its role in facilitating conservative surgery and noted the improved prognostic information associated with pathological complete response to such therapy, particularly in patients with ‘HER2 positive’ and ‘Triple negative (ductal)’ tumors [89], which may allow earlier change from an ineffective regimen.
The Panel considered that the choice of neoadjuvant chemotherapy should be made on the same basis as applied in the selection of postoperative adjuvant treatments. The Panel supported the incorporation of an anti-HER2 drug in the neoadjuvant therapy for patients with ‘HER2 positive’ disease, but did not support dual HER2 targeting at this point in time. The Panel did not support cytotoxic neoadjuvant therapy for tumors with low proliferation or high endocrine responsiveness.

neoadjuvant endocrine therapy

The Panel was almost unanimous in supporting the use of neoadjuvant endocrine therapy as an option for postmenopausal patients with highly endocrine-responsive disease. If given, the Panel considered that such treatment should be continued until maximal response or for a minimum of 4–8 months.

bisphosphonates

The Panel did not support the use of bisphosphonates for antitumor effect in either pre- [32] or postmenopausal [90] patients.

male breast cancer

Adjuvant tamoxifen was strongly supported, but only a slim majority would consider aromatase inhibitors in patients with contraindications to tamoxifen, such as thrombosis. The Panel did not support extended endocrine treatment beyond 5 years for male breast cancer. The lack of any evidence on these latter two points was acknowledged.

summary of systemic treatment recommendations

The approach to treatment within breast cancer subtypes greatly simplifies the definition of therapy indications, since the subtypes themselves incorporate many of the risk and predictive factors used in previous consensus recommendations. The broad recommendations are summarized in Table 3 and essentially indicate endocrine therapy alone for patients with clinicopathologically classified ‘Luminal A’ disease (except in defined high-risk cases), chemo-endocrine therapy for ‘Luminal B’, the addition of anti-HER2 therapy in the presence of ‘HER2 positivity’, and a reliance on chemotherapy for most patients with ‘Triple negative’ disease (e.g. those with invasive ductal carcinoma).
View this table:

Table 3. Systemic treatment recommendations for subtypes




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funding

Support for the conference was provided by SONK from registration fees paid by the conference attendees and by Grant No. CA75362 from the United States National Cancer Institute.

Last edited by 'lizbeth; 01-09-2014 at 09:55 AM.. Reason: omissions
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Old 01-10-2014, 12:55 PM   #5
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Re: HER2/HR positive early breast cancer patients have the highest disease-free survi

Let's see ...

"In this recent cohort in which treatment is representative of current clinical
practice..."

What treatment plan has the Dutch been using for Her2 +++ breast cancer?
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Old 02-10-2014, 09:05 AM   #6
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Re: HER2/HR positive early breast cancer patients have the highest disease-free survi

This is very encouraging. I have been in a lot of the literature and have found very little info on the Disease Free Survival rate for triple positive. Most of what I have found has been a little discouraging with the recurrence rates. Thanks for sharing.
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