SABCS: Focus on Adjuvant and Neoadjuvant Therapy

Kathy D. Miller, MD


December 03, 2010

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It's December, and for those of us who focus on breast cancer, that means it's time to pack our bags and head to San Antonio. Many of us have spent time going through the program and looking for the highlights. Many meetings become known by themes of major results that are presented. For instance, the last ASCO [American Society of Clinical Oncology] meeting was really the year of local therapy developments in breast cancer, where many trials addressing local therapy questions reported results that really should affect our practice.

Looking ahead to this year, in San Antonio; this is going to be the year of adjuvant and neoadjuvant therapy, with very few results of interest for patients in the metastatic setting (at least from my quick review of the program), but some very interesting studies in the adjuvant and neoadjuvant setting.

In the adjuvant setting, we should see the first results of the MA-27 trial, asking a very practical question: Is there a difference between 1 aromatase inhibitor and another? The long-awaited results of the AZURE [Does Adjuvant Zoledronic acid redUce REcurrence in patients with high-risk localised breast cancer?] trial are also on the program. It's not clear if they will have enough events to report the results. I'm told that it will be right down to the wire as to whether they have enough events for the analysis. However, further information on the benefit of bisphosphonates would be really helpful and could really clarify that ongoing question, and drive important changes in practice.

Also, on a practical level, a CALGB [Cancer and Leukemia Group B] trial that evaluated 4 vs6 cycles of standard adjuvant chemotherapy (or similar duration of weekly paclitaxel) in a 2-by-2 design to compare this with a weekly paclitaxel substitute for adjuvant chemotherapy. And, does the duration of therapy matter?

None of those trials really addresses major biology questions, although perhaps the bisphosphonate trial does in a way. However, they are really practical studies that could influence our treatment of patients on a day-to-day basis.

The neoadjuvant studies, though, I find even more interesting, and I think will foreshadow results to come in larger adjuvant trials. Neoadjuvant trials in the HER-2 positive setting include a direct comparison of neoadjuvant trastuzumab and neoadjuvant lapatinib from the German breast cancer group, and the NEOALTO [Neoadjuvant Lapatinib and/or Trastuzumab Treatment Optimisation] trial that looked at that same direct comparison (although in a setting of a slightly different chemotherapy regimen), but also including the combination of trastuzumab and lapatinib.

A study from an Italian group is looking at what pertuzumab might bring to bear for HER-2 positive patients. Investigators are using the neoadjuvant setting as a way to get results a bit earlier with pathologic complete response as the primary endpoint, and also to be able to interrogate patients' tumors and try to understand who might benefit from these novel agents, who doesn't benefit, and what that might tell us about resistance.

Another trial from the German group looked at bevacizumab, an area hotly debated and contested, to see whether that agent has value and benefit for our patients in the metastatic setting. Adjuvant trials are ongoing; they are still enrolling patients. So, the results of that neoadjuvant trial to see (with pathologic complete response as the primary endpoint) whether adding bevacizumab improves that early readout of efficacy could be very important for the future of those adjuvant trials.

There will undoubtedly be surprises, some good, perhaps some bad, and some that will take a while to know if they're good or bad. But, it promises to be an important meeting for both existing patients in the adjuvant setting and helping us look to the future in those key biologic subsets.


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