New International Guidelines for Advanced Breast Cancer Released

Fran Lowry

September 22, 2014

The latest international consensus guidelines for the management of advanced breast cancer were published online September 18 in the Annals of Oncology and September 20 in the Breast.

The advanced breast cancer 2 (ABC2) guidelines urge more research and clinical trials into treatment for advanced disease, and describe advanced breast cancer patients as a "historically neglected population."

In particular, the guidelines note, more research is needed to find the best treatments for patients with breast cancer that has spread to the liver, pleural cavity, or the skin; patients with HER2-positive advanced breast cancer who relapse during or shortly after adjuvant treatment with trastuzumab; patients with stage IV disease; and men with advanced breast cancer who require treatment with aromatase inhibitors, such as anastrozole, exemestane, and letrozole.

"Our plea is for strong commitment from everyone involved — academia, the pharmaceutical industry, funders, and advocacy groups — to develop well-designed, high-quality, multidisciplinary trials for advanced breast cancer," said guidelines committee cochair Fatima Cardoso, MD, who is director of the breast unit at the Champalimaud Cancer Center in Lisbon, Portugal.

"This is of critical importance, as many questions are still unanswered relating to management strategies, better drugs and drug use, and individualizing treatments so that they are specific to a particular patient and their tumor," Dr. Cardoso said in a statement.

The guidelines were formulated by a group of experts from around the world who met at the second International Consensus Guidelines Conference on Advanced Breast Cancer in Lisbon in November 2013.

The conference was organized by the European School of Oncology with the goal to improve outcomes for all patients with advanced breast cancer. Some 1100 participants from 71 countries attended, and the new guidelines were codeveloped by the European Society of Molecular Oncology.

The ABC2 consensus guidelines contain several updates to the first set of guidelines, which were issued in 2011.

One new focus is on inoperable locally advanced breast cancer, which occurs in 15% of breast cancer patients in developed countries and in up to 60% of patients in developing countries.

"There are very few clinical trials providing data for the best treatment of locally advanced breast cancer," Dr. Cardoso said.

The ABC2 guidelines include new recommendations for triple-negative breast cancer, HER2-positive breast cancer, and hormone-receptor-positive disease. They also provide information gleaned from recent clinical trials on pertuzumab (Perjeta) and trastuzumab emtansine (Kadcyla) for HER2-positive disease and everolimus (Afinitor) for hormone-receptor-positive disease.

"The care of women with metastatic breast cancer is highly variable around the world," ABC2 cochair Eric Winer, MD, director of breast oncology at the Dana-Farber Cancer Institute in Boston, told Medscape Medical News.

"The guidelines that have existed, as far as I am aware, have largely been focused on the [American] population, or the United States and selected other countries. The ABC2 guidelines are designed to be useful to people around the world, in both economically advantaged and disadvantaged societies," Dr. Winer explained.

He acknowledged that it might be difficult for the guidelines to be applied globally because of the disparity in resources that exist around the world, but many of them can be used regardless of a country's wealth.

"On some level, one can think of some of these as aspirational in some countries. But we have set out certain basic principles, such as multidisciplinary care and palliative care, which are universally applicable," he said.

The committee that wrote the guidelines only recommended treatments for which solid evidence exists, Dr. Winer reported.

"We set forth what we thought would be the best possible care, and in some situations we were also able to make recommendations that in many societies would lead to somewhat less expensive care," he said.

As an example, the guidelines suggest optimal frequency for imaging.

"Sometimes imaging tests are done too frequently," he said. Suggesting that CT scans and other imaging tests can be done less frequently could save money yet still provide effective screening, Dr. Winer explained.

The ABC2 guidelines also emphasize the importance of nursing and psychosocial care, in addition to medical care, in the treatment of a patient with advanced breast cancer.

"These are patients who may live with this disease for many years in some situations, and for shorter periods of time in others, but there are real symptom management issues and psychological issues. If we are going to provide optimal care, it is going to take a number of different people to provide that care. Compared with the cost of some of the drugs we have, providing somebody with counseling and better symptom management may be well within the means of many countries," Dr. Winer said.

Ann Oncol. Published online September 18, 2014. Full text

Breast. Published online September 20, 2014. Abstract

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