De-escalating and escalating treatments for early-stage breast cancer: the St. Gallen International Expert Consensus Conference on the Primary Therapy of Early Breast Cancer 2017 |
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| Institution: | 1. Breast Cancer Program, Istituto Europeo di Oncologia, Milano, Italy;2. Breast Oncology Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA;3. Department of Surgery, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria;4. Klinik St. Anna, Luzern, Switzerland;5. German Breast Group, Neu-Isenburg, Germany;6. Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, USA;7. Department of Medical Oncology, Institut Jules Bordet, UniversitÕ Libre de Bruxelles, Brussels, Belgium;8. Tumor and Breast Center ZeTuP, St. Gallen;9. Breast Center, Kantonsspital St. Gallen, St. Gallen, Switzerland;10. Institut de Cancérologie Gustave Roussy, Villejuif, France;11. Memorial Sloan Kettering Cancer Center, New York, USA;12. Karolinska Institute and University Hospital, Stockholm, Sweden;13. University of Bordeaux, Bordeaux, France;14. Universitäts-Frauenklinik Tübingen, Tübingen, Germany;15. Champalimaud Cancer Centre, Lisbon, Portugal;16. Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, USA;17. Hospital Universitario 12 de Octubre, Madrid, Spain;18. Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK;19. Institut für Pathologie, Charité Universitätsmedizin Berlin, Berlin, Germany;20. Azienda Usl Toscana Centro, Prato, Italy;21. Rigshospitalet, Copenhagen, Denmark;22. Peter McCallum Cancer Centre, Melbourne, Australia;23. Marmara University School of Medicine, Istanbul, Turkey;24. University of Toronto, Mount Sinai Hospital, Toronto, Canada;25. University of Munich, München, Germany;26. Comprehensive Cancer Center, University of Michigan, Ann-Arbor, USA;27. National Taiwan University Hospital, Taipei, Taiwan;28. University of Ulm, Ulm, Germany;29. The National Cancer Institute, Cairo University, Cairo, Egypt;30. Medical University of Gdansk, Gdansk, Poland;31. Hospital Affiliated to Military Medical Science, Beijing, China;32. Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrensky University Hospital, Gothenburg, Sweden;33. Baylor College of Medicine, Houston, USA;34. Institute of Oncology Southern Switzerland, Ospedale San Giovanni, Bellinzona, Switzerland;35. Sunnybrook Odette Cancer Center, University of Toronto, Toronto, Canada;36. National Cancer Center, Ilsandong-gu, Goyang-si, Gyeonggi-do, Korea;37. Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands;38. LKH Salzburg, Paracelsus Medical University Clinics, Salzburg, Austria;39. N.N. Petrov Research Institute of Oncology, St. Petersburg, Russian Federation;40. Fudan University Cancer Hospital, Shanghai, China;41. The Royal Marsden, Sutton, Surrey, UK;42. Graduate School of Medicine Kyoto University, Sakyo-ku, Kyoto City, Japan;43. Breast Cancer Now Research Centre, The Institute of Cancer Research, London, UK;44. University of Milan, Milan, Italy;45. Istituto Europeo di Oncologia, Milan, Italy;46. Hamamatsu Oncology Center, Hamamatsu, Japan;47. McMaster University, Hamilton, Canada;48. National Cancer Center, Chaoyang District, Beijing, China |
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| 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 intensity, 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 several interventions that may reduce surgical morbidity, including acceptance of 2 mm margins 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 of 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 chemotherapy 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 suppression in premenopausal women, and extended therapy for postmenopausal women. However, low-risk patients can avoid these treatments. Finally, the Panel recommended bisphosphonate use in postmenopausal women to prevent breast cancer recurrence. The Panel recognized 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 managing constraints of treatment cost and access that may affect care in both the developed and developing world. |
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