November 23, 2011 — New guidelines for the treatment of advanced breast cancer, specifically metastatic breast cancer, have been developed by an international group of breast cancer experts.
These guidelines are scheduled to be published in the January 2012 issue of The Breast.
They were developed by a task force chaired by Fatima Cardoso, MD, director of the breast cancer unit and breast cancer research program at the Champalimaud Cancer Center in Lisbon, Portugal, and Eric Winer, MD, professor of medicine at Harvard Medical School and director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, Massachusetts.
The guidelines were finalized at the first Advanced Breast Cancer (ABC1) consensus conference, held November 3 to 5 in Lisbon. The meeting attracted more than 800 participants from around the world, and "it went very well," Dr. Cardoso told Medscape Medical News.
"We had a panel of the world's leading experts, and voted on statements; we reached consensus on nearly everything," she said. The guidelines will summarize recommendations for advanced metastatic breast cancer.
A future meeting (ABC2), which will produce a future set of guidelines, will tackle locally advanced breast cancer, which is a separate entity and was not addressed this time around, she noted.
First Set of Guidelines
"These will be the first guidelines for advanced breast cancer that tackle all of the issues that we feel need to be addressed," Dr. Cardoso said." We designed them so that they can be adapted in all countries."
She noted that the National Comprehensive Cancer Network already has some guidelines, but they are specific to the United States and are not broadly adhered to by clinicians.
The work of the task force, set up by the European School of Oncology, started in 2006. A set of principles/general recommendations for the treatment of advanced breast cancer were published in 2007 (Breast. 2007;16:9-10); these were followed by the publication of detailed discussions and further recommendations in 2009 and 2010 (J Natl Cancer Inst. 2009;101:1174-1181 and 2010;102:456-463).
However, the work was not advancing fast enough. It became clear that a dedicated consensus guidelines conference was needed to produce a more detailed set of guidelines covering all of the issues, Dr. Cardoso explained.
"Management of metastatic disease has suffered from a lack of strong international collaboration in clinical and translational research that could lead to faster advances and evidenced-based care standards. As a result, patients and carers often feel lost in a maze of many different opinions and scattered guideline efforts," Dr. Winer said in a statement.
One of the points emphasized in the new guidelines is that the treatment of advanced breast cancer should be carried out by a multidisciplinary team, Dr. Cardoso reported in an interview. "This is so obvious that it hardly needs writing down," she said, "but it is not done in practice."
At the moment, advanced breast cancer is often managed by an oncologist working in isolation; because there are few established standards of care, individual doctors do what they consider is best for the patient. "We jokingly refer to this as eminence-based medicine," she said.
Improving Survival
Metastatic breast cancer is not the initial diagnosis very often; it accounts for only about 10% of new cases, Dr. Cardoso explained. It is seen more commonly in patients who progress. Even when early breast cancer is adequately treated, about 30% of patients relapse and present with metastases, she said.
Once breast cancer has spread, it is incurable, Dr. Cardoso noted. "It is incurable, but it is treatable," she emphasized. "This is the main message that we want to send out — that even though it is incurable, it is not something that you should give up on.... If it is treated correctly, with all the knowledge that we already have available, we can improve overall survival."
Currently, medical textbooks estimate the median survival for advanced breast cancer to be 2 to 3 years. "But in real life and in our clinical practice, we see examples of much longer survival," she said. At the ABC1 conference, there were patient advocates who have been living with metastatic breast cancer for 8 to 9 years.
"We want them not to be the exception, but to be the majority of patients with this disease," she said.
"We know from early-stage breast cancer that survival has improved with the use of international consensus guidelines — and now we must do the same for metastatic disease," she said. "To achieve that, we need several things."
"We need to be clear about the message we are giving to our patients, and it is not an easy message to give or to receive," she explained. "We need to be clear that we are not aiming for a cure, but we are aiming to control the disease and to turn it into a chronic condition.... This is not to say that research-wise, we should not continue to fight to find a cure."
"Next, we need to provide the best care. This is always provided by a multidisciplinary team and in specialized breast units," she said. This includes identifying each subtype of breast cancer (e.g., HER2-positive, estrogen-receptor positive, triple-negative), and treating them accordingly. "This is treatment tailoring. It is already being done in early breast cancer, but we must do it also in advanced disease," she said.
Last but not least is access to palliative care — in particular, "easy access to effective control of pain, including opiates, which does not always happen," she said. "Some patients do not even have access to morphine because of the hurdles that are placed in the way, and they suffer pain unnecessarily."
Men can also have breast cancer, albeit rarely, and they were not forgotten at ABC1; some guidelines specific for male patients with advanced breast cancer were also issued, Dr. Cardoso noted.
These guidelines are scheduled to be published in the January 2012 issue of The Breast.
They were developed by a task force chaired by Fatima Cardoso, MD, director of the breast cancer unit and breast cancer research program at the Champalimaud Cancer Center in Lisbon, Portugal, and Eric Winer, MD, professor of medicine at Harvard Medical School and director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, Massachusetts.
The guidelines were finalized at the first Advanced Breast Cancer (ABC1) consensus conference, held November 3 to 5 in Lisbon. The meeting attracted more than 800 participants from around the world, and "it went very well," Dr. Cardoso told Medscape Medical News.
"We had a panel of the world's leading experts, and voted on statements; we reached consensus on nearly everything," she said. The guidelines will summarize recommendations for advanced metastatic breast cancer.
A future meeting (ABC2), which will produce a future set of guidelines, will tackle locally advanced breast cancer, which is a separate entity and was not addressed this time around, she noted.
First Set of Guidelines
"These will be the first guidelines for advanced breast cancer that tackle all of the issues that we feel need to be addressed," Dr. Cardoso said." We designed them so that they can be adapted in all countries."
She noted that the National Comprehensive Cancer Network already has some guidelines, but they are specific to the United States and are not broadly adhered to by clinicians.
The work of the task force, set up by the European School of Oncology, started in 2006. A set of principles/general recommendations for the treatment of advanced breast cancer were published in 2007 (Breast. 2007;16:9-10); these were followed by the publication of detailed discussions and further recommendations in 2009 and 2010 (J Natl Cancer Inst. 2009;101:1174-1181 and 2010;102:456-463).
However, the work was not advancing fast enough. It became clear that a dedicated consensus guidelines conference was needed to produce a more detailed set of guidelines covering all of the issues, Dr. Cardoso explained.
"Management of metastatic disease has suffered from a lack of strong international collaboration in clinical and translational research that could lead to faster advances and evidenced-based care standards. As a result, patients and carers often feel lost in a maze of many different opinions and scattered guideline efforts," Dr. Winer said in a statement.
One of the points emphasized in the new guidelines is that the treatment of advanced breast cancer should be carried out by a multidisciplinary team, Dr. Cardoso reported in an interview. "This is so obvious that it hardly needs writing down," she said, "but it is not done in practice."
At the moment, advanced breast cancer is often managed by an oncologist working in isolation; because there are few established standards of care, individual doctors do what they consider is best for the patient. "We jokingly refer to this as eminence-based medicine," she said.
Improving Survival
Metastatic breast cancer is not the initial diagnosis very often; it accounts for only about 10% of new cases, Dr. Cardoso explained. It is seen more commonly in patients who progress. Even when early breast cancer is adequately treated, about 30% of patients relapse and present with metastases, she said.
Once breast cancer has spread, it is incurable, Dr. Cardoso noted. "It is incurable, but it is treatable," she emphasized. "This is the main message that we want to send out — that even though it is incurable, it is not something that you should give up on.... If it is treated correctly, with all the knowledge that we already have available, we can improve overall survival."
Currently, medical textbooks estimate the median survival for advanced breast cancer to be 2 to 3 years. "But in real life and in our clinical practice, we see examples of much longer survival," she said. At the ABC1 conference, there were patient advocates who have been living with metastatic breast cancer for 8 to 9 years.
"We want them not to be the exception, but to be the majority of patients with this disease," she said.
"We know from early-stage breast cancer that survival has improved with the use of international consensus guidelines — and now we must do the same for metastatic disease," she said. "To achieve that, we need several things."
"We need to be clear about the message we are giving to our patients, and it is not an easy message to give or to receive," she explained. "We need to be clear that we are not aiming for a cure, but we are aiming to control the disease and to turn it into a chronic condition.... This is not to say that research-wise, we should not continue to fight to find a cure."
"Next, we need to provide the best care. This is always provided by a multidisciplinary team and in specialized breast units," she said. This includes identifying each subtype of breast cancer (e.g., HER2-positive, estrogen-receptor positive, triple-negative), and treating them accordingly. "This is treatment tailoring. It is already being done in early breast cancer, but we must do it also in advanced disease," she said.
Last but not least is access to palliative care — in particular, "easy access to effective control of pain, including opiates, which does not always happen," she said. "Some patients do not even have access to morphine because of the hurdles that are placed in the way, and they suffer pain unnecessarily."
Men can also have breast cancer, albeit rarely, and they were not forgotten at ABC1; some guidelines specific for male patients with advanced breast cancer were also issued, Dr. Cardoso noted.
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