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Consensus conference on de-escalating
and escalating treatments for early-stage
breast cancer
Annals of Oncology
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.
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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