Personalizing the Treatment of Women With Early Breast Cancer

Highlights of the St Gallen International Expert Consensus on the Primary Therapy of Early Breast Cancer 2013

A. Goldhirsch; E. P. Winer; A. S. Coates; R. D. Gelber; M. Piccart-Gebhart; B. Thürlimann; H.-J. Senn; Panel members

Disclosures

Ann Oncol. 2013;24(9):2206-2223. 

In This Article

Abstract and Introduction

Abstract

The 13th St Gallen International Breast Cancer Conference (2013) Expert Panel reviewed and endorsed substantial new evidence on aspects of the local and regional therapies for early breast cancer, supporting less extensive surgery to the axilla and shorter durations of radiation therapy. It refined its earlier approach to the classification and management of luminal disease in the absence of amplification or overexpression of the Human Epidermal growth factor Receptor 2 (HER2) oncogene, while retaining essentially unchanged recommendations for the systemic adjuvant therapy of HER2-positive and 'triple-negative' disease. The Panel again accepted that conventional clinico-pathological factors provided a surrogate subtype classification, while noting that in those areas of the world where multi-gene molecular assays are readily available many clinicians prefer to base chemotherapy decisions for patients with luminal disease on these genomic results rather than the surrogate subtype definitions. Several multi-gene molecular assays were recognized as providing accurate and reproducible prognostic information, and in some cases prediction of response to chemotherapy. Cost and availability preclude their application in many environments at the present time. Broad treatment recommendations are presented. Such recommendations do not imply that each Panel member agrees: indeed, among more than 100 questions, only one (trastuzumab duration) commanded 100% agreement. The various recommendations in fact carried differing degrees of support, as reflected in the nuanced wording of the text below and in the votes recorded in supplementary Appendix S1,availableatAnnals of Oncology online. Detailed decisions on treatment will as always involve clinical consideration of disease extent, host factors, patient preferences and social and economic constraints.

Introduction

The 2 years since the 2011 St Gallen Consensus[1] have seen substantial progress in evidence relevant to various aspects of the treatment of early invasive breast cancer. The genomic atlas of the disease[2] has emphasized its heterogeneity, and suggested that genomic studies may potentially inform treatment decisions such as the use of aromatase inhibitors.[3,4] Further data became available reducing the necessity for axillary dissection.[5,6] Studies presented at the 2012 ESMO meeting clarified the optimal duration of adjuvant trastuzumab in HER2-positive disease.[7,8] The duration of adjuvant tamoxifen was addressed by the ATLAS study, which suggested a significant benefit for extending such treatment to 10 years rather than 5 years.[9]

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