Initial Treatment of Patients with Primary Breast Cancer: Evidence, Controversies, Consensus

Abstract

The St. Gallen International Consensus Conference on the treatment of patients with primary breast cancer has been held regularly (every second year in the last six years) for more than 30 years. This year, the findings of the International St. Gallen Consensus Panel and their implications for clinical practice were again discussed by a German working group of leading breast cancer specialists. Five of the breast cancer specialists from Germany were also members of this yearʼs St. Gallen panel. A comparison between the St. Gallen recommendations and the annually updated treatment guidelines of the Gynecologic Oncology Group (AGO 2017) and the S3-guideline agreed upon in 2017 is useful. The recommendations of the St. Gallen panel represent an international cross-section of opinions of experts from different countries and different disciplines, while the S3-guideline and AGO guidelines are evidence-based. The motto of this yearʼs 15th St. Gallen Conference was “Escalating and De-Escalating”. The rationale behind this concept was to promote more individualized treatment and thereby reduce overtreatment as well as undertreatment.

Key words

St. Gallen consensus 2017 - early breast cancer - systemic therapy - local therapy - multigene expression - pathology - pregnancy - male breast cancer

^* St. Gallen Panel Expert

• References/Literatur

• 1 Diagnosis and treatment of patients with primary and metastatic breast cancer (Version 2017 1D). Online: http://www.ago-online.de last access: 23.03.2017
• 2 Jagsi R, Chadha M, Moni J. et al. Radiation field design in the ACOSOG Z0011 (Alliance) Trial. J Clin Oncol 2014; 32: 3600-3606
• 3 Kuehn T, Bauerfeind I, Fehm T. et al. Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study. Lancet Oncol 2013; 14: 609-618
• 4 Online: http://www.astro.org last access: 24.04.2017
• 5 Online: http://www.estro.org last access: 24.04.2017
• 6 Smith BD, Arthur DW, Buchholz TA. et al. Consensus Statement der ASTRO. Int J Rad Oncol Bio Phys 2009; 74: 987-1001
• 7 Polgàr C, Van Limbergen E, Pötter R. et al. Patient selection for accelerated partial-breast irradiation (APBI) after breast-conserving surgery: recommendations of the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) breast cancer working group based on clinical evidence (2009). Radiother Oncol 2010; 94: 264-273
• 8 Donker M, van Tienhoven G, Straver ME. et al. Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS): a randomised, multicentre, open-label, phase 3 non-inferiority trial. Lancet Oncol 2014; 15: 1303-1310
• 9 Buus R, Sestak I, Kronenwett R. et al. Comparison of EndoPredict and EPclin with Oncotype DX Recurrence Score for prediction of risk of distant recurrence after endocrine therapy. J Natl Cancer Inst 2016; 108: djw149
• 10 Sestak I, Buus R, Cuzick J. et al. Comprehensive comparison of prognostic signatures for breast cancer recurrence in TransATAC. SABCS 2016, S6-05.
• 11 Francis PA, Regan MM, Fleming GF. et al. Adjuvant ovarian suppression in premenopausal breast cancer. N Engl J Med 2015; 372: 436-446
• 12 Pagani O, Regan MM. Francis PA; TEXT and SOFT Investigators, International Breast Cancer Study Group. Exemestane with ovarian suppression in premenopausal breast cancer. N Engl J Med 2014; 371: 1358-1359
• 13 Cuzick J, Sestak J, Baum M. et al. Effect of anastrozole and tamoxifen as adjuvant treatment for early-stage breast cancer: 10 year analysis of the ATAC trial. Lancet Oncol 2010; 11: 1135-1141
• 14 Regan MM, Neven P, Giobbie-Hurder A. et al. Assessment of letrozole and tamoxifen alone and in sequence for postmenopausal women with steroid hormone receptor-positive breast cancer: the BIG 1-98 randomised clinical trial at 8.1 years median follow-up. Lancet Oncol 2011; 12: 1101-1108
• 15 Sparano JA, Gray RJ, Makower DF. et al. Prospective validation of 21-gene expression assay in breast cancer. N Engl J Med 2015; 373: 2005-2014
• 16 Nitz U. Prospective WSG Phase III PlanB trial: Clinical outcome at 5-year follow up and impact of 21 Gene Recurrence Score result, central/local-pathological review of grade, ER, PR and Ki67 in HR+/HER2- high risk node-negative and -positive breast cancer. Vortrag ESMO/ECCO-Jahrestagung 2016, LBA 8.
• 17 Gluz O, Nitz UA, Christgen M. et al. West German Study Group Phase III Plan B Trial: first prospective outcome data for the 21-gene recurrence score assay and concordance of prognostic markers by central and local pathology assessment. J Clin Oncol 2016; 24: 2341-2349
• 18 Cardoso F, vanʼt Veer LJ, Bogaerts J. et al. 70-Gene signature as an aid to treatment decisions in early-stage breast cancer. N Engl J Med 2016; 375: 717-729
• 19 Vaz-Luis I, Ottesen RA, Hughes ME. et al. Outcomes by tumor subtype and treatment pattern in women with small, node-negative breast cancer: a multi-institutional study. J Clin Oncol 2014; 32: 2142-2150
• 20 Ignatov T, Eggemann H, Burger E. et al. Management of small T1a/b breast cancer by tumor subtype. Breast Cancer Res Treat 2017; 163: 111-118
• 21 Kolben T, Harbeck N, Wuerstlein R. et al. Endocrine sensitivity is decisive for patient outcome in small node-negative breast cancers (BC) (pT1a,b) – results from the Munich Cancer Registry. Breast 2014; 24: 24-31
• 22 National Comprehensive Cancer Network. Online: http://www.nccn.org last access: 24.04.2017
• 23 von Minckwitz G, Schneeweiss A, Loibl S. et al. Neoadjuvant carboplatin in patients with triple-negative and HER2-positive early breast cancer (GeparSixto; GBG 66): a randomised phase 2 trial. Lancet Oncol 2014; 15: 747-756
• 24 Wolff AC, Hammond ME, Hicks DG. et al. Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guidelines update. J Clin Oncol 2013; 31: 3997-4013
• 25 Slamon DJ, Eiermann W, Robert NJ. et al. Ten-year follow-up of BCIRG-006 comparing doxorubicin plus cyclophosphamide followed by docetaxel with doxorubicin plus cyclophosphamide followed by docetaxel and trastuzumab with docetaxel, carboplatin and trastuzumab in HER2-positive early breast cancer patients. SABCS 2015, S5-04.
• 26 Von Minckwitz G, Procter MJ, De Azambuja E. et al. Adjuvant pertuzumab and trastuzumab in early HER2-positive breast cancer. N Engl J Med 2017; DOI: 10.1056/NEJMoa1703643.
• 27 Pivot XB, Bondarenko I, Dvorkin M. et al. A randomized, double-blind, phase III study comparing SB3 with originator trastuzumab in patients treated by neoadjuvant therapy for HER2-positive early breast cancer. ASCO 2017, Poster 509.
• 28 Stebbing J, Baranau YV, Baryash V. et al. Double-blind, randomized phase III study to compare the efficacy and safety of CT-P6, trastuzumab biosimilar candidate versus trastuzumab as neoadjuvant treatment in HER2 positive early breast cancer. ASCO 2017, Poster 510.
• 29 Untch M, Jackisch C, Schneeweiss A. et al. Nab-paclitaxel versus solvent-based paclitaxel in neoadjuvant chemotherapy for early breast cancer (GeparSepto-GBG 69): a randomised, phase 3 trial. Lancet Oncol 2016; 17: 345-356
• 30 Masuda N, Lee SJ, Ohtani S. et al. Adjuvant capecitabine for breast cancer after preoperative chemotherapy. N Engl J Med 2017; 376: 2147-2159
• 31 Nangia J, Wang T, Niravath P. et al. Scalp Cooling Alopecia Prevention Trial. SABCS 2016, S5-02.
• 32 Early Breast Cancer Trialistsʼ Collaborative Group (EBCTCG). Coleman R, Powles T. et al. Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials. Lancet 2015; 386: 1353-1361
• 33 Gnant M, Mlineritsch B, Stoeger H. et al. Adjuvant endocrine therapy plus zoledronic acid in premenopausal women with early-stage breast cancer: 62-month follow-up from the ABCSG-12 randomised trial. Lancet Oncol 2011; 12: 631-641