Practice Update | Onology

EDITOR’S PICKS 6

Consensus conference on de-escalating and escalating treatments for early-stage breast cancer Take-home message • The St. Gallen International Breast Conference Panel discussed treatment options for early-stage breast cancer, seeking to escalate or de-escalate therapy based on likelihood of improvement in outcomes. • The Panel favored interventions that would result in reduced surgical morbidity. The Panel additionally favored neoadjuvant therapy in HER2-positive and triple-negative, stage 2 and 3 breast cancer patients. For high-risk patients, the Panel favored nodal irradiation and escalating recommendations for adjuvant endocrine treatment to include ovarian suppression in premenopausal women and extended therapy for postmenopausal women. Annals of Oncology

Abstract The 15th St. Gallen International Breast Cancer Conference 2017 in Vienna, Austria reviewed substantial new evidence on loco-regional and systemic therapies for early breast cancer. Treatments were assessed in light of their inten- sity, duration and side effects, seeking where appropriate to escalate or de-escalate therapies based on likely benefits as predicted by tumor stage and tumor biology. The Panel favored sev- eral interventions which may reduce surgical morbidity, including acceptance of 2mm mar- gins for DCIS, the resection of residual cancer (but not baseline extent of cancer) in women undergoing neoadjuvant therapy, acceptance of sentinel node biopsy following neoadjuvant treatment for many patients, and the preference for neoadjuvant therapy in HER2 positive and triple-negative, stage II and III breast cancer. The Panel favored escalating radiation therapy with regional nodal irradiation in high risk patients, while encouraging omission of boost in low risk patients. The Panel endorsed gene expression signatures that permit avoidance of chemother- apy in many patients with ER positive breast cancer. For women with higher risk tumors, the Panel escalated recommendations for adjuvant endocrine treatment to include ovarian suppres- sion in premenopausal women, and extended therapy for postmenopausal women. However, low risk patients can avoid these treatments. Finally, the Panel recommended bisphospho- nate use in postmenopausal women to prevent breast cancer recurrence. The Panel recog- nized that recommendations are not intended for all patients, but rather to address the clinical needs of the majority of common presentations. Individualization of adjuvant therapy means adjusting to the tumor characteristics, patient comorbidities and preferences, and manag- ing constraints of treatment cost and access that may affect care in both the developed and developing world. De-escalating and escalating treatments for early stage breast cancer: the St. Gallen Inter- national Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017. Ann Oncol 2017 Jun 21;[EPub Ahead of Print], G Curigliano, HJ Burstein, EP Winer, et al.

COMMENT By Lee S. Schwartzberg MD, FACP T he St. Gallen conference makes recommendations on the treatment of early-stage breast cancer based on international expert consensus opin- ion. This year’s conference focused on de-escalating surgical approaches such as accepting a 2-mm margin for DCIS and smaller resections based on residual tumor size after neoadjuvant treatment. Notably, they endorsed incorporating one of several genomic assays into the decision-making process for ER-positive cancers and the need for chemother- apy. They agreed on some escalation of therapy with a recommendation of bis- phosphonate use in postmenopausal women, which differs from the NCCN recommendations, and regional nodal

irradiation if patients had positive nodal disease removed at surgery. In general, more precise subtyping and risk assessment has allowed more personalized adjuvant care, leading to different treatment approaches based on a combination of patient factors, tumor size and stage, and tumor biology.

Dr Schwartzberg is the Executive Director of the West Cancer Center, and he serves as Professor of Medicine and Division Chief of Hematology/ Oncology at The University of Tennessee Health Science Center.

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